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," on 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
2015
Open to Public
Inspection
Name of the organization
Delta Dental of Wisconsin Inc
 
Employer identification number
39-6094742
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) UNIVERSITY OF MANITOBA

402 ADMINISTRATION BUILDING
WINNIPEG,MANITOBA  
CA 		98-6008078 501(C)(3) 14,490   N/A N/A FUNDING FOR PROJECT TO RESEARCH DENTAL CARIES IN SEVERAL POPULATIONS, INCLUDING INUIT AND AMERICAN INDIAN ALASKA NATIVE CHILDREN
(2) MARQUETTE UNIVERSITY SCHOOL OF DENTISTRY
PO BOX 1881
MILWAUKEE,WI53201 		39-0806251 501(C)(3) 370,086   N/A N/A RURAL FELLOWSHIP, SCHOLARSHIPS, MISSION OF MERCY GRANT, CAPITAL CAMPAIGN FOR SCHOOL EXPANSION
(3) MARSHFIELD CLINIC RESEARCH FOUNDATION
1000 NORTH OAK AVE
MARSHFIELD,WI54449 		39-0452970 501(C)(3) 1,361,000   N/A N/A DEVELOPMENT OF SCHOOL BASED SEALANT SOFTWARE PROGRAM, RESEARCH INTO MODELS OF DENTAL CARE FOR DIABETIC AND PRE-DIABETIC INDIVIDUALS
(4) STATE OF WISCONSIN - DEPT OFHEALTH SERVICES
1 WEST WILSON ST
ROOM 650
MADISON,WI53707 		39-6006469 STATE OF WI 350,000   N/A N/A SEAL-A-SMILE, A STATEWIDE SCHOOLD-BASED ORAL CARE PROGRAM
(5) WISCONSIN DENTAL ASSOCIATION FOUNDATION
6737W WASHINGTON ST SUITE 2360
WEST ALLIS,WI53214 		39-0965289 501(C)(3) 95,000   N/A N/A MISSION OF MERCY, DONATED DENTAL SERVICES FOR LOW INCOME, SMILE DAY (FREE ORAL HEALTH EDUCATION EVENT)
(6) DOOR COUNTY MEMORIAL HOSPITAL FOUNDATION
1843 MICHIGAN ST
STURGEON BAY,WI54235 		39-0806324 501(C)(3) 50,000   N/A N/A FUNDING FOR EXPANSION OF CLINIC THAT PROVIDES DENTAL CARE TO CHILDREN AND FOR LOW INCOME ADULTS
(7) SPECIAL OLYMPICS WISCONSIN INC
2310 CROSSROADS DR
MADISON,WI53718 		39-1176591 501(C)(3) 25,000   N/A N/A SPECIAL SMILES, AN ORAL SCREENING AND EDUCATION FOR SPECIAL OLYMPICS ATHLETES
(8) BUILDING FOR KIDS INC
100 W COLLEGE AVE
APPLETON,WI54911 		39-1706260 501(C)(3) 7,500   N/A N/A MILES OF SMILES, FREE ORAL HEALTH EDUCATION EVENT
(9) WAUKESHA COMMUNITY DENTAL CLINIC INC
210 NW BARSTOW ST
WAUKESHA,WI53188 		30-0436162 501(C)(3) 11,073   N/A N/A EQUIPMENT FOR USE IN OPERATORY SETTING TO SERVE CHILDREN AND SPECIAL NEEDS YOUNG ADULTS REQUIRING DENTAL-RELATED SURGERY
(10) COLUMBIA ST MARY'S FOUNDATION
1730 S 13TH ST
MILWAUKEE,WI53204 		39-0806315 501(C)(3) 50,000   N/A N/A FUNDING FOR SAFETY NET CLINIC PROVIDING FOR URGENT DENTAL CARE NEEDS OF LOW INCOME
(11) BREWERS COMMUNITY FOUNDATION INC
ONE BREWERS WAY
MILWAUKEE,WI53214 		39-1970152 501(C)(3) 25,000   N/A N/A TEAM SMILE, FREE DENTAL CARE DAY FOR YOUTH AT RISK
(12) BOYS & GIRLS CLUB OF GREATER MILWAUKEE INC
1558 N 6TH STREET
MILWAUKEE,WI53212 		39-0806292 501(C)(3) 25,000   N/A N/A FUNDING FOR ORAL HEALTH PROGRAM, INCLUDING SCREENINGS, REFERRAL ASSISTANCE, BRUSHING PROGRAM, AND ORAL HEALTH EDUCATION
(13) CHURCH HEALTH SERVICES INC
115 CENTER STREET
BEAVER DAM,WI53916 		39-1759669 501(C)(3) 110,000   N/A N/A FUNDING FOR DENTAL CLINIC FOR UNINSURED INDIVIDUALS OR INDIVIDUALS WITH MEDICAID, AS WELL AS DENTAL SCREENING FOR AMISH CHILDREN
(14) AMERICAN DIABETES ASSOCIATION
375 BISHOPS WAY SUITE 220
BROOKFIELD,WI53005 		13-1623888 501(C)(3) 10,000   N/A N/A ORAL HEALTH EDUCATION PROGRAM FOR CHILDREN WITH DIABETES
(15) CHILDRENS HOSPITAL OF WISCONSIN INC
9000 W WISCONSIN AVE
MILWAUKEE,WI53201 		39-0812532 501(C)(3) 26,076   N/A N/A FUNDING FOR A SUMMIT OF WISCONSIN DENTAL LEADERS TO DISCUSS GAP IN ORAL HEALTH SERVICES FOR INDIVIDUALS WITH SPECIAL NEEDS
(16) UNITED WAY OF PORTAGE COUNTY INC
1100 CENTERPOINT DRIVE SUITE 302
STEVENS POINT,WI54481 		39-0831152 501(C)(3) 316,706   N/A N/A SUPPORT FOR UNITED WAY AGENCIES IN PORTAGE COUNTY
(17) TRI-COUNTY COMMUNITY DENTAL CLINIC
9 TRI-PARK WAY
APPLETON,WI54914 		47-0862462 501(C)(3) 40,000   N/A N/A FUNDING FOR FOCUS ON CHILDREN PROGRAM
(18) THE LAKES COMMUNITY HEALTH CENTER INC
7665 US HWY 2
IRON RIVER,WI54847 		35-2297925 501(C)(3) 62,150   N/A N/A FUNDING FOR EQUIPMENT/SUPPLIES TO PROVIDE DENTAL SERVICES TO LOW INCOME RESIDENTS IN THREE NORTHERN WISCONSIN COUNTIES
(19) NORTHEAST WISCONSIN TECHNICAL COLLEGE EDUCATION FOUNDATION INC
2740 WEST MASON ST
GREEN BAY,WI54307 		23-7069405 501(C)(3) 43,000   N/A N/A FUNDING FOR CLINIC EXPANSION OF OPERATORIES TO ALLOW FOR SEEING MORE LOW INCOME PATIENTS, SCHOLARSHIPS FOR STUDENTS
(20) ST MARY'S HOSPITAL MEDICAL CENTER OF THE HOSPITAL SISTERS
1726 SHAWANO AVE
GREEN BAY,WI54303 		39-0818682 501(C)(3) 38,112   N/A N/A FUNDING FOR EXPANSION OF ORAL SURGERY CAPABILITIES FOR CHILDREN AND SPECIAL NEEDS ADULTS WITH MEDICAID COVERAGE
(21) WISCONSIN WOMEN'S HEALTH FOUNDATION
2503 TODD DRIVE
MADISON,WI53713 		39-1900678 501(C)(3) 15,000   N/A N/A FUNDING FOR PROGRAMS TO HELP RURAL WOMEN DEAL WITH HEALTH ISSUES, INCLUDING ORAL HEALTH
(22) UNIVERSITY OF MICHIGAN
1011 N UNIVERSITY RM 2391
ANN ARBOR,MI48190 		38-6006309 501(C)(3) 25,213   N/A N/A GRANT FOR SILVER DIAMINE FLUORIDE RESEARCH
(23) ST ANN CENTER FOR INTERGENERATIONAL CARE
2801 E MORGAN AVE
MILWAUKEE,WI53207 		39-1757756 501(C)(3) 200,000   N/A N/A FUNDING FOR CONSTRUCTION OF NEW DENTAL CLINIC FOR INDIVIDUALS WITH SPECIAL NEEDS
(24) OPEN ARMS FREE CLINIC INC
797 EAST GENEVA ST
ELKHORN,WI53121 		45-4475625 501(C)(3) 50,000   N/A N/A FUNDING FOR DENTAL CLINIC PROVIDING CARE TO UNINSURED, LOW INCOME RESIDENTS OF WALWORTH COUNTY
(25) BREAD OF HEALING INC
1821 NORTH 16TH ST
MILWAUKEE,WI53211 		81-0669867 501(C)(3) 10,000   N/A N/A FUNDING FOR LAB FEES FOR DENTURES, PARTIALS, AND OTHER DENTAL SUPPLIES AT BREAD OF HEALING DENTAL CLINIC
(26) COMMUNITY DENTAL CLINIC
520 HANDEYSIDE LANE
FORT ATKINSON,WI53538 		20-5297560 501(C)(3) 53,200   N/A N/A FUNDING FOR ORAL SURGERY EQUIPMENT FOR CHILDREN AND SPECIAL NEEDS ADULTS WHO NEED SEDATION IN ORDER TO CARE FOR THEIR DENTAL NEEDS
(27) UCLA SCHOOL OF DENTISTRY
10833 LE CONTE AVE CHS 20-114
LOS ANGELES,CA90095 		95-6006143 501(C)(3) 27,000   N/A N/A FUNDING FOR PROJECT TO RESEARCH DENTAL CARIES IN NATIVE AMERICANS
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
27
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) 2015
Page 2

Schedule I (Form 990) 2015
Page 2
Part III
Grants and Other Assistance to Domestic Individuals. Complete if the organization answered "Yes" on 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, Part I, Line 2 Procedures for monitoring use of grant funds. Delta Dental of Wisconsin (DDW) carefully reviews each grant application it receives. Grants are awarded only after a thorough evaluation of both the recipient organization itself and the specific initiative outlined in the grant request. Grants of more than $25,000 are reviewed and approval is determined by the Charitable Fund Committee, comprised of DDW Board and management team members. Additionally, all grant requests of more than $200,000 are reviewed and approval determined by Delta Dental of Wisconsin's Board of Directors. All recipients of grants in excess of $25,000 are required to file an annual report with DDW that describes in detail how the organization used DDW's funding and the outcomes achieved. These reports are available for review by both DDW's management team and the Company's Board of Directors. For smaller grants and general donations, Delta Dental may require follow-up reporting, depending on the organization and project.
Schedule I (Form 990) 2015



Additional Data


Software ID: 15000238
Software Version: 2015v2.1