Note: To capture the full content of this document, please select landscape mode (11" x 8.5") when printing.

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
Adventist Health SystemWest
DBA Adventist Health
Employer identification number
95-3484589
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) ADRA
12501 Old Columbia Pike
Silver Spring,MD20904 		52-1314847 501(c)(3) 10,000 0     Hurricane relief grant
(2) AH Clearlake Hospital Inc
15630 18th Ave
Clearlake,CA95422 		68-0395149 501(c)(3) 300,000 0     Project Restoration
(3) Loma Linda University
24760 Stewart St
Loma Linda,CA92354 		95-1816009 501(c)(3) 13,000 0     Education Grant-School of Religion
(4) Northern CA Conference
401 Taylor Blvd
Pleasant Hill,CA94523 		95-1816050 501(c)(3) 25,000 0     Fire relief grant
(5) Pacific Union College
1 Angwin Ave
Angwin,CA94508 		77-0578450 501(c)(3) 15,000 0     Health Services Grant
(6) Sacramento Adventist Academy
5601 Winding Way
Sacramento,CA95608 		94-1431179 501(c)(3) 30,000 0     Education Grant & Building Project
(7) St Helena Hospital
10 Woodland Rd
St Helena,CA94574 		94-1279779 501(c)(3) 100,000 0     Fire relief grant
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
7
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) 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)
(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
Grantmaker's Description of How Grants are Used Funding provided to other organizations is provided to recipients with the understanding that the funds are being used only for the designated purposes. No monitoring is conducted by AH.
Schedule I (Form 990) 2017



Additional Data


Software ID: 17005038
Software Version: 2017v2.2