Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
KERSHAWHEALTH
 
Employer identification number
57-6005963
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21, for any recipient that received more than $5,000. Part II can be duplicated if additional space is needed.
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) COMMUNITY MEDICAL CLINIC OF KERSHAW COUNTY
110 C EAST DEKALB ST
CAMDEN,SC29020 		57-1074191 501(C)(3) 90,000       FINANCIAL ASSISTANCE
(2) UNITED WAY OF KERSHAW COUNTY
PO BOX 737 632 WEST DEKALB ST
CAMDEN,SC29020 		57-0717334 501(C)(3) 10,000       CHARITABLE CONTRIBUTION
(3) KERSHAW COUNTY SCHOOL DISTRICT
1301 DUBOSE COURT
CAMDEN,SC29020 		57-6000368 GOV'T 60,000       ATHLETIC TRAINER SALARY
(4) KERSHAW COUNTY
515 WALNUT ST
CAMDEN,SC29020 		57-6000368 GOV'T 43,379       911 DISPATCHER SALARY
(5) SANDHILLS MEDICAL FOUNDATION
PO BOX 366
MCBEE,SC29101 		57-0672342 501(C)(3) 311,652       GRANT PASSTHROUGH














2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image
5
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
0
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2012
Page 2

Schedule I (Form 990) 2012
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance












Part IV
Supplemental Information.
Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional information.
Identifier Return Reference Explanation
PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION WORKS CLOSELY WITH THE ORGANIZATIONS RECEIVING THE FUNDS AND ENSURES THAT THE FUNDS ARE USED IN ACCORDANCE WITH THE OPERATIONS INTENDED. IN ADDITION, THE ORGANIZATION INCURS EXPENSES ON BEHALF OF THE HOSPITAL FOUNDATION TO ADVANCE HEALTH CARE IN KERSHAW COUNTY TO PROVIDE FOR FUNDRAISING EFFORTS ON BEHALF OF THE ORGANIZATION.
Schedule I (Form 990) 2012


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