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
DARTMOUTH-HITCHCOCK CLINIC
 
Employer identification number
22-2519596
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) Granite State United Way
46 South Main St
Concord,NH03301 		02-6006033 501(c)(3) 8,370   FMV   Program Support
(2) Indian Stream Health Center
141 Corliss Ln
Colebrook,NH03756 		20-0999212 501(C)(3) 15,500   FMV   Program/Clinic Svcs
(3) David's House
461 Mount Support Rd
Lebanon,NH03766 		22-2593431 501(C)(3) 10,230   FMV   Program Support
(4) The Trustees of Dartmouth College
1 Rope Ferry Road
Lebanon,NH03755 		02-0222111 501(C)(3) 310,000   FMV   Educ and Prog Sppt
(5) Advance Transit
PO Box 1027
Wilder,VT05088 		22-2558708 501(C)(3) 33,723   FMV   Transportn Subsidy
(6) City Year NH Pledge
287 Cloumbus Avenue
Boston,MA02116 		22-2882549 501(C)(3) 7,750   FMV   Program Support
(7) Mascoma Valley Health Initiative
PO Box 2013
Canaan,NH03741 		75-2991608 501(C)(3) 5,115   FMV   Program Support
(8) Southwestern VT Healthcare
100 Hospital Dr Box 41
Bennington,VT05201 		03-0179435 501(C)(3) 5,813   FMV   Program Support
(9) American Cancer Society
250 Williams Street NW
Atlanta,GA30303 		13-1788491 501(c)(3) 5,231   FMV   Program Support
(9)
(10)
(11)
(12)
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
9
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) The Trustees of Dartmouth College 13 61,209   FMV  
(2) D-H Tuition Reimbursement Program 604 228,005   FMV  
(3) Varnum Nursing Awards 43 12,397   FMV  
(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
Form 990, Schedule I Description of Organization's Procedures for Monitoring the Use of Grants For each award established by Dartmouth-Hitchcock Clinic there are written and established guidelines and procedures. Grant award payments are processed in accordance with the specific terms of each of the grants noted above. The Dartmouth Institute Scholarships (TDI) are paid directly to the College on the behalf of the individuals receiving the award. The coordinators of the program(s) are responsible for assuring that all terms are met, including proper documentation of expenses with receipts.
Schedule I (Form 990) 2014



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