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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.
MediumBullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2017
Open to Public
Inspection
Name of the organization
SIOUXLAND COMMUNITY HEALTH CENTER
 
Employer identification number
42-1374894
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) NEBRASKA AIDS PROJECT
250 S 77TH STREET SUITE A
OMAHA,NE68114
47-0786622 501(C)(3) 49,723       HIV CASE MANAGE
(2) JACKSON RECOVERY CENTERS
800 5TH STREET
SIOUX CITY,IA51101
39-1900255 501(C)(3) 30,219       BEHAVIOR CASE MANAGE
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
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2017
Page 2

Schedule I (Form 990) 2017
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
noncash assistance
(e) Method of valuation (book,
FMV, appraisal, other)
(f) Description of noncash assistance
(1) RENTAL ASSITANCE PROGRAM 35 75,626      
(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 MONITORING OF GRANT FUNDS: NEBRASKA AIDS PROJECT CONTINUED TO BE A SUBCONTRACTED AGENCY IN ORDER TO PROVIDE CONTRACTUAL HIV/AIDS SERVICES IN SOUTHWEST IA. THEY WERE CHOSEN ON THE BASIS OF PRIOR EXPERIENCE WITH WORKING WITH TARGETED POPULATION, AND STAFF CREDENTIALS/EXPERIENCE. THE AGENCY SUBMITS MONTHLY FINANCIAL REPORTS WITH EXPENSE DOCUMENTATION AND TIME TRACKING IN ORDER TO BE REIMBURSED. THEY ALSO SUBMIT THEIR ANNUAL AUDIT FOR REVIEW AND AN ON-SITE MONITORING REVIEW IS PERFORMED ANNUALLY. JACKSON RECOVERY CENTERS WAS SELECTED TO BE A SUBCONTRACTED AGENCY TO PROVIDE ON-SITE BEHAVIORAL HEALTH CASE MANAGEMENT SERVICES. JACKSON RECOVERY CENTERS WAS SELECTED BASED ON PRIOR EXPERIENCE WITH WORKING WITH THE TARGETED POPULATION. JACKSON RECOVERY CENTERS STAFF MAINTAINS TIME AND EFFORT RECORDS AND SUBMITS MONTHLY INVOICES FOR SERVICES. STAFF ARE SUPERVISED AND EVALUATED BY THE HEALTH CENTER CHIEF MEDICAL OFFICER. PATIENTS WITHIN THE HIV PROGRAM HAVE THE POTENTIAL OF QUALIFYING FOR THE RENTAL ASSISTANCE PROGRAM. THIS IS A SERVICE PROVIDED BY SIOUXLAND COMMUNITY HEALTH CENTER TO INDIVIDUALS WHO QUALIFY. INDIVIDUALS MUST DEMONSTRATE A NEED FOR FINANCIAL ASSISTANCE AND THEY MUST FOLLOW-UP REGULARLY WITH THE STAFF AT THE CLINIC.
Schedule I (Form 990) 2017



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