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.
lBullet Information about Schedule I (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2014
Open to Public
Inspection
Name of the organization
BREAST CANCER SURVIVORS FOUNDATION
INC
Employer identification number
27-2827805
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 Domestic Organizations and Domestic Governments. Complete if the organization answered "Yes" on 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 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) ARLINGTON FREE CLINIC
2921 11TH STREET SOUTH
ARLINGTON,VA22204 		54-1671883 (C) (3 8,000       CHARITABLE
(2) BERGEN VOLUNTEER MEDICAL INITIATIV
241 MOORE STREET
HACKENSACK,NJ07601 		20-2633437 (C)(3) 7,500       CHARITABLE
(3) CLINIC BY THE BAY
VOLUNTEERS IN MEDICINE
4877 MISSION STREET
SAN FRANCISCO,CA94112 		26-2593712 (C)(3) 10,000       CHARITABLE
(4) COMMUNITY HEALTH
26 W CHICAGO AVENUE
CHICAGO,IL60622 		36-3831793 (C)(3) 20,000       CHARITABLE
(5) COMMUNITY VOLUNTEERS IN MEDICINE
300B LAWRENCE DRIVE
WEST CHESTER,PA19380 		23-2944553 (C)(3) 10,000       CHARITABLE
(6) GOOD SAMARITAN CLINC
305 2 UNION STREET
MORGANTON,NC28655 		56-1939030 (C)(3) 10,000       CHARITABLE
(7) LAKELAND VOLUNTEERS
1021 LAKELAND HILLS BLVD
LAKELAND,FL33805 		52-2351630 (C)(3) 6,000       CHARITABLE
(8) MAMOU HEALTH RESOURCES INC
300 SOUTH ST
MAMOU,LA70554 		75-0949444 (C)(3) 8,000       CHARITABLE
(9) NW ARKANSAS FREE HEALTH CLINIC
10 S COLLEGE AVENUE
FAYETTEVILLE,AR72701 		58-1691790 (C)(3) 6,500       CHARITABLE
(10) TAYLORS FREE MEDICAL CLINIC
400 W MAIN ST
TAYLORS,SC29687 		20-1715911 (C)(3) 11,340       CHARITABLE
(11) VOLUNTEERS IN MEDICINE MONROE
811 WEST 2ND STREET
BLOOMINGTON,IN47403 		20-4383915 (C)(3) 7,000       CHARITABLE
(12) COMMUNITY HEALTH HUB
5 S WASHINGTON AVE
JERMYN,PA184331121 		27-3582779 (C)(3) 6,975       CHARITABLE
(13) COMMUNITY CARE CENTER FOR FORSYTH
2135 NEW WALKERTOWN RD
WINSTON SALEM,NC27101 		58-1403699 (C)(3) 10,000       CHARITABLE
(14) DAVIDSON MEDICAL MINISTRIES CLINIC
PO BOX 584
LEXINGTON,NC27293 		56-1746266 (C)(3) 10,000       CHARITABLE
(15) HEALTH QUEST OF UNION COUNTY
415 E FRANKLIN ST
MONROE,NC28112 		56-2117596 (C)(3) 7,000       CHARITABLE
(16) KILEEN FREE HEALTH CLINIC
718 N 2ND ST SUITE A
KILEEN,TX76541 		74-2724725 (C)(3) 10,000       CHARITABLE
(17) PHYSICAN CARE CLINIC
2675 N DECATUR RD SUITE 406
DECATUR,GA30033 		58-2107579 (C)(3) 6,000       CHARITABLE
(18) SCOTLAND COMMUNITY HEALTH CLINIC
PO BOX 2050
LAURINBURG,NC28352 		20-2841940 (C)(3) 8,000       CHARITABLE
(19) ST VINCENT DE PAUL MEDICAL CLINIC
420 WEST WATKINS PO BOX 13600
PHOENIX,AZ85002 		86-0096789 (C) (3 7,500       CHARITABLE
(20) THE FREE CLINIC OF DANVILLE
122 SOUTH RIDGE ST
DANVILLE,VA24541 		54-1667654 (C)(3 6,500       CHARITABLE
(21) TOMAGWA HEALTHCARE MINISTRIES
455 SCHOOL ST SUITE 30
TUMBALL,TX77375 		76-0280324 (C)(3) 7,500       CHARITABLE
(22) VENICE FAMILY CLINIC
604 ROSE AVENUE
VENICE BEACH,CA90291 		95-2769432 (C)(3) 10,000       CHARITABLE
(23) VOLUNTEERS IN MEDICINE JACKSONVILLE
41 EAST DUVAL ST
JACKSONVILLE,FL32202 		75-3002172 (C)(3) 7,500       CHARITABLE
(24) VOLUNTEERS IN WILKES-BARRE
190 N PENNSYLVANIA
WILKESBARRE,PA18702 		20-3531527 (C)(3) 7,500       CHARITABLE
(25) WARREN COUNTY FREE CLINIC
546 W RIDGEWAY ST
WARREN,NC27589 		20-4307481 (C)(3) 10,000       CHARITABLE
(26) ANN SILVERMAN HEALTH CLINIC
595 WEST STATE ST
DOYLESTOWN,PA18901 		23-2892823 (C)(3) 6,000       CHARITABLE
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
26
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) 2014
Page 2

Schedule I (Form 990) 2014
Page 2
Part III
Grants and Other Assistance to Domestic Individuals. 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
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Part IV
Supplemental Information. Provide the information required in Part I, line 2, Part III, column (b), and any other additional information.
Return Reference Explanation
SCHEDULE I, PAGE 1, PART I, LINE 2 GRANT RECIPIENTS SIGN AN AGREEMENT THAT THEY WILL USE THE GRANT ASSISTANCE FOR THE PURPOSE(S) DESCRIBED IN THE AGREEMENT.
Schedule I (Form 990) 2014



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