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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.
lBullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2019
Open to Public
Inspection
Name of the organization
Delta Dental of Washington
 
Employer identification number
91-0621480
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) American Academy of Pediatrics
345 PARK BLVD
ITASCA,IL60143 		36-2275597 501(c)(3) 50,000       Funding to support national fluoridation education
(2) Public Health Seattle King County
401 5TH AVE
Seattle,WA98104 		KING COUNTY 153,300       Funding to expand ABCD
(3) Choice Regional Health Network
1217 4TH AVE E STE 200
OLYMPIA,WA98506 		46-0360899 501(c)(3) 76,706       Funding to support Care Coordination
(4) Commu Health Care School Based Health Ctr
1148 BROADWAY SUITE 100
TACOMA,WA98402 		91-1349657 501(c)(3) 61,000       Capital funding for clinic expansion
(5) Olympia Union Gospel Mission
PO BOX 7668
OLYMPIA,WA98507 		91-1680748 501(c)(3) 29,751       Funding to support increasing dental access
(6) North Sound ACH
1204 RAILROAD AVE SUITE 200
BELLINGHAM,WA98225 		81-4680689 501(c)(3) 44,500       Funding to support sealant program, Funding to support teledentistry, Funding toward increasing dental access
(7) Yakima Valley Farm Workers Clinic
PO BOX 190
TOPPENISH,WA98948 		91-1019392 501(c)(3) 122,360       Risk corridor for teledentistry pilot
(8) Project Access NW
1111 HARVARD AVE
SEATTLE,WA98122 		20-4377921 501(c)(3) 10,000       Funding to cover Medicaid spend down
(9) Better Health Together
1023 W RIVERSIDE
SPOKANE,WA99201 		90-0997482 501(c)(3) 40,000       Funding to support LIN coordination
(10) Communities in Schools
905 W RIVERSIDE AVE
SPOKANE,WA99201 		58-1289174 501(C)(3) 88,450       Funding to support sealant program
(11) Northwest Portland Area Indian Health
2121 SW BROADWAY
PORTLAND,OR97201 		93-0718154 501(C)(3) 45,000       Funding for Dental Therapy evaluation
(12) Spokane Regional Health District
1101 W COLLEGE AVE
SPOKANE,WA99201 		91-1527532 501(C)(3) 36,964       Funding to support opioid education and LIN Evaluation
(13) Aging and Long-term Care of Eastern Washington
1222 N POST STREET
SPOKANE,WA99201 		91-1017706 501(C)(3) 8,091       Funding to support care coordination
(14) Frontier Behavior Health
107 SOUTH DIVISION STREET
SPOKANE,WA99202 		91-0853801 501(C)(3) 78,268       Funding to support oral health coordination
(15) Spokane Neighborhood Action Partners
3102 W FT GEORGE WRIGHT DR
SPOKANE,WA99224 		91-1311127 501(C)(3) 30,000       Funding to support oral health access
(16) Port Gamble S'Klallam Dental Clinic
31912 LITTLE BOSTON RD NE
KINGSTON,WA98346 		91-0875163 501(C)(3) 100,000       Capital funding for clinic expansion
(17) Klickitat Valley Health Rural Health Center Dental
310 S ROOSEVELT
GOLDENDALE,WA98620 		91-6001738 501(C)(3) 125,000       Capital funding for clinic expansion
(18) Society of Teachers of Family Medicine
11400 TOMAHAWK CREEK PARK
LEAWOOD,KS66211 		51-0187107 501(c)(3) 196,020       FUNDING TO SUPPORT SMILES FOR LIFE
(19) International Community Health Services Dental Cli
PO Box 3007
SEATTLE,WA98114 		91-0947084 501(C)(3) 150,000       Capital funding for clinic expansion
(20) HealthPoint Dental Clinic
955 POWELL AVE SW
RENTON,WA98057 		91-0884412 501(C)(3) 75,000       Capital funding for clinic expansion
(21) Bellingham Technical College
3028 LINDBERGH AVE
BELLINGHAM,WA98225 		91-1658027 501(C)(3) 7,500       Funding for program support
(22) Seattle Indian Health Board
611 12th AVE SOUTH
SEATTLE,WA98144 		91-0869056 501(C)(3) 10,000       Funding to participate in Task Force
(23) NYU OHNEP
105 EAST 17TH STREET
NEW YORK,NY10003 		13-5562308 501(C)(3) 10,000       Funding to support oral health integration
(24) Latino Community Fund
PO BOX 30669
SEATTLE,WA98103 		20-5987399 501(c)(3) 10,000       Funding to participate in Task Force
(25) Asian Pacific Cultural Center
4851 S TACOMA WAY
TACOMA,WA98409 		91-1854410 501(C)(3) 10,000       Funding to participate in Task Force
(26) Urban League of Metropolitan Seattle
105 14TH AVE
SEATTLE,WA98122 		91-0575954 501(C)(3) 10,000       Funding to participate in Task Force
(27) Washington Association for Community Health
101 CAPITOL WAY N
OLYMPIA,WA98501 		91-1323282 501(C)(3) 43,978       Funding to support Dental Learning Network
(28) Proteus Fund
15 RESEARCH DRIVE
AMHERST,MA01002 		04-3243004 501(C)(3) 40,000       Funding for Census capacity building and Oral Health
(29) WA Department of Health
PO BOX 47822
OLYMPIA,WA98504 		WASHINGTON 32,000       Funding to support water operator education
(30) LHAQ'TEMISH FOUNDATIONS
2665 KWINA ROAD
BELLINGHAM,WA98226 		91-1836621 501(C)(3) 30,000       Funding for provider training
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
30
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) 2019
Page 2

Schedule I (Form 990) 2019
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 THE GRANTEE IS REQUIRED TO SIGN A GRANT AGREEMENT STATING THAT THEY WILL USE THE FUNDS ONLY FOR PURPOSES OUTLINED IN THE GRANT AGREEMENT AND APPLICATION. THE GRANTEE IS REQUIRED TO FILE REPORTS ON REGULAR INTERVALS OUTLINING THE USE OF FUNDS. GRANTEE IS ALSO REQUIRED TO RETURN UNUSED FUNDING IF APPLICABLE.
Schedule I (Form 990) 2019



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