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
2016
Open to Public
Inspection
Name of the organization
HALIFAX REGIONAL HOSPITAL INC
 
Employer identification number
54-0648699
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
noncash assistance		 (h) Purpose of grant
or assistance
(1) YMCA OF SOUTH BOSTON AND HALIFAX COUNTY
690 HAMILTON BLVD
SOUTH BOSTON,VA24592 		54-0951231 501(C)(3) 25,000       SUPPORT
(2) SENTARA HEALTHCARE
6015 POPLAR HALL DRIVE
NORFOLK,VA23502 		52-1271901 501(C)(3) 875,189       OVERHEAD ALLOCATIONS
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
2
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) 2016
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Schedule I (Form 990) 2016
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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
noncash assistance		 (e) Method of valuation (book,
FMV, appraisal, other)		 (f) Description of noncash assistance
(1) ELISE THOMSON CLARK MEMORIAL FUNDS APPLIED TO INDIVIDUAL PATIENT ACCOUNTS 68 40,276      
(2) EVERY WOMAN'S LIFE FUNDS APPLIED TO INDIVIDUAL PATIENT ACCOUNTS 35 10,202      
(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
PART I, LINE 2: AS PART OF THE SENTARA HEALTHCARE SYSTEM ("THE SYSTEM"), THE ORGANIZATION DONATES FUNDS TO ITS 501(C)(3) PARENT ORGANIZATION, SENTARA HEALTHCARE, IN FURTHERANCE OF THE SYSTEM'S MISSION TO IMPROVE HEALTH EVERYDAY THROUGH THE PROVISION OF HEALTH SERVICES, AND THE PROMOTION OF HEALTH, MEDICAL EDUCATION, AND THE SOCIAL, CULTURAL, EDUCATIONAL, AND ECONOMIC DEVELOPMENT OF THE COMMUNITY. EXPENDITURE OF SUCH FUNDS IS OVERSEEN BY AN INDEPENDENT COMMUNITY BOARD WHICH MANAGES THE BUSINESS AND AFFAIRS OF THE SYSTEM. GRANTS FROM HALIFAX REGIONAL HOSPITAL, INC. ARE ONLY MADE TO AFFILIATES WHOSE FINANCIAL RECORDS ARE MAINTAINED BY THE HOSPITAL.
SCHEDULE I, PART III INDIVIDUAL GRANTS ARE FOR THE PROVISION OF HEALTH CARE TO THE UNINSURED.
Schedule I (Form 990) 2016



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