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
CROSSETT HEALTH FOUNDATION DBA
ASHLEY COUNTY MEDICAL CENTER
Employer identification number
71-0236870
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) DELTA MEMORIAL HOSPITAL
811 US-65
DUMAS,AR71639 		71-0276839 501(C)(3) 17,575   CASH VALUE   HOSPITAL PREPARDNESS
(2) ASHLEY COUNTY MEDICAL CENTER
PO BOX 400
CROSSETT,AR71635 		71-0236870 501(C)(3) 42,469   CASH VALUE   HOSPITAL PREPARDNESS
(3) BRADLEY COUNTY MEDICAL CENTER
404 SOUTH BRADLEY
WARREN,AR71671 		71-0797499 501(C)(3) 7,829   CASH VALUE   HOSPITAL PREPARDNESS
(4) DREW MEMORIAL HOSPITAL
778 SCOGGIN DRIVE
MONTICELLO,AR71655 		35-2414105 501(C)(3) 8,292   CASH VALUE   HOSPITAL PREARDNESS
(5) CHICOT MEMORIAL HOSPITAL
2729 HWY 65 82 SOUTH
LAKE VILLAGE,AR71653 		38-3807713 501(C)(3) 8,519   CASH VALUE   HOSPITAL PREPARDNESS
(6) MCGEHEE HOSPITAL INC
900 S THIRD ST
MCGEHEE,AR71654 		36-4664248 501(C)(3) 7,829   CASH VALUE   HOSPITAL PREPARDNESS
(7) DEWITT HOSPITAL & NURSING HOME INC
PO BOX 32
DEWITT,AR72042 		95-4896822 501(C)(3) 8,203   CASH VALUE   HOSPITAL PREPARDNESS
(8) BAPTIST HEALTH-STUTTGART
1703 NORTH BUERKLE
STUTTGART,AR72160 		71-0236856 501(C)(3) 7,828   CASH VALUE   HOSPITAL PREPARDNESS
(9) JEFFERSON REGIONAL MEDICAL CENTER
1600 W 40TH AVE
PINE BLUFF,AR71603 		71-0329353 501(C)(3) 7,828   CASH VALUE   HOSPITAL PREPARDNESS
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) 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 (Form 990) 2015



Additional Data


Software ID:  
Software Version: