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
WELLMONT HEALTH SYSTEM
 
Employer identification number
62-1636465
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) AMERICAN CANCER SOCIETY
508 PRINCETON RD
SUITE 102
JOHNSON CITY,TN37601 		64-0329099 501(C) 19,000       RELAY FOR LIFE SPONS
(2) APPALACHIAN MOUNTAIN PROJECT ACCESS
1060 DRAGON RD
OAKWOOD,VA24631 		26-0069167 501(C) 40,000       SPONSORSHIP
(3) BARTER THEATRE
PO BOX 867
ABINDGON,VA24212 		54-6000120 501(C) 15,000       SPONSORSHIP
(4) BRISTOL MOTOR SPEEDWAY
PO BOX 3966
BRISTOL,TN37625 		62-1016760   10,000       CHILDREN'S CHARITIES
(5) BRISTOL CONVENTION & VISITORS BUREA
PO BOX 519
BRISTOL,VA24203 		54-0150315 501(C) 25,000       SPONSOR PICK PINK
(6) EAST TENNESSEE STATE UNIVERSITY
PO BOX 70732
JOHNSON CITY,TN37614 		23-7092731 501(C) 20,000       ATHLETIC SPONSORSHIP
(7) FUN FEST KINGSPORT TN
151 EAST MAIN ST
KINGSPORT,TN37660 		62-0446834 501(C) 17,750       SPONSORSHIP
(8) KINGSPORT CHAMBER OF COMMERCE
151 EAST MAIN ST
KINGSPORT,TN37662 		62-0446834 501(C) 25,835       ANNUAL SPONSORSHIP
(9) KINGSPORT TOMORROW
301 LOUIS ST
SUITE 303
KINGSPORT,TN37660 		58-1941002 501(C) 10,000       HEALTHCARE SYMPOSIUM
(10) OTHERS 5000

 
  		  116,351       SPONSORSHIPS
(11) RHYTHM & ROOTS REUNION
PO BOX 1927
BRISTOL,VA24203 		72-1526206 501(C) 10,000       SPONSORSHIP
(12) SUSAN G KOMEN FOR THE CURE
PO BOX 5835
KINGSPORT,TN37663 		84-1689067 501(C) 55,102       SPONSORSHIP
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image
 
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
 
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
PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS INSIDE THE UNITED STATES SCHEDULE I, PAGE 1, PART I, LINE 2 ALL REQUESTS FOR CHARITABLE ASSISTANCE ARE REVIEWED BY THE SENIOR VICE PRESIDENT OF SYSTEM ADVANCEMENT. THE REQUEST FOR GRANT FUNDS IS EVALUATED ON THE BASIS OF THE FOLLOWING ITEMS: THE DEGREE TO WHICH THE REQUEST SUPPORTS WELLMONT HEALTH SYSTEM'S MISSION, REPRESENTATION OF WELLMONT HEALTH SYSTEM AS A GOOD CORPORATE CITIZEN, AND THE ANNUAL BUDGET. THE SENIOR VICE PRESIDENT THEN MAKES A DETERMINATION OF APPROVAL FOR ALL REQUESTS AND THE REQUEST IS SENT DIRECTLY TO ACCOUNTS PAYABLE FOR PAYMENT. WELLMONT HEALTH SYSTEM MAKES MINIMAL GRANTS (LESS THAN 5,000 PER ENTITY) THROUGHOUT THE YEAR. THE USE OF THESE GRANT FUNDS IS NOT MONITORED BY WELLMONT HEALTH SYSTEM AS THESE GRANTS ARE MADE IN GENERAL SUPPORT OF THE GRANT RECIPIENT.
Schedule I (Form 990) 2012


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