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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
PENN HIGHLANDS HEALTHCARE
 
Employer identification number
32-0345810
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) BROOKVILLE HOSPITAL
100 HOSPITAL ROAD
BROOKVILLE,PA15825 		25-0984595 501(C)(3) 20,848       PASS-THROUGH SUPPORT
(2) CLEARFIELD HOSPITAL
809 TURNPIKE DRIVE
CLEARFIELD,PA16830 		25-0979346 501(C)(3) 21,998       PASS-THROUGH SUPPORT
(3) DUBOIS REGIONAL MEDICAL CENTER
100 HOSPITAL AVENUE
DUBOIS,PA15801 		25-1490707 501(C)(3) 36,098       PASS-THROUGH SUPPORT
(4) ELK REGIONAL HEALTH CENTER
763 JOHNSONBURG RD
ST MARYS,PA15857 		25-0585280 501(C)(3) 19,148       PASS-THROUGH SUPPORT
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
4
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)
(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: THE GOLF TOURNAMENT FUNDS ARE DISTRIBUTED BASED ON DESIGNATIONS MADE BY DONORS BUT IF DONORS DO NOT MAKE DESIGNATIONS THEN THE FUNDS ARE DISTRIBUTED EVENLY AMONG THE PENN HIGHLANDS HOSPITALS. THE EXPENSES OF THE TOURNAMENT ARE DISTRIBUTED EVENLY AMONG THE HOSPITALS.
Schedule I (Form 990) 2017



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