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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
IOWA HEALTHIEST STATE INITIATIVE
 
Employer identification number
45-4570642
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) CITY OF MANNING
321 CENTER STREET
MANNING,IA51455 		42-6004919   5,000       FURTHER THE EFFORTS OF IMPROVING THE HEALTH OF IOWANS
(2) CITY OF WEST UNION
PO BOX 151
WEST UNION,IA52175 		42-6005366   5,000       FURTHER THE EFFORTS OF IMPROVING THE HEALTH OF IOWANS
(3) IRVING ELEMENTARY-WATERLOO COMMUNITY SCHOOL DISTRICT
1516 WASHINGTON STREET
WATERLOO,IA50702 		42-6003910 501(C)(3) 5,000       FURTHER THE EFFORTS OF IMPROVING THE HEALTH OF IOWANS
(4) WAVERLY AREA PARTNERSHIP FOR HEALTHY LIVING
1706 FOREST AVENUE
WATERLOO,IA50702 		46-1579356   5,000       FURTHER THE EFFORTS OF IMPROVING THE HEALTH OF IOWANS
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
0
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) PAYMENTS TO RETAILERS ON BEHALF OF INDIVIDUALS WHO RECEIVE SNAP\EBT\FOOD STAMPS FOR PURCHASING FRESH FRUITS AND VEGETABLES AS AN INCENTIVE TO PURCHASE ADDITIONAL FRUITS AND VEGETABLES 21450 570,565   CASH SPENT  
(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
PART I, LINE 2: PART I, QUESTION 2-THE PROGRAM IS NOT ALLOWED TO TRACK REIMBURSEMENT AT THE INDIVIDUAL\HOUSEHOLD LEVEL DUE TO CONFIDENTIALITY, BUT IT IS TRACKED BY SITE (RETAILER). ELIGIBILITY FOR INDIVIDUALS\HOUSEHOLDS IS DETERMINED BY THE U.S. DEPARTMENT OF AGRICULTURE (USDA). SITES MUST BE AN APPROVED SNAP PROVIDER BY THE USDA. EACH SITE HAS A SIGNED CONTRACT THAT OUTLINES THE USE OF THE FUNDS. EACH SITE IS REQUIRED TO SUBMIT DATA POINTS VIA AN ONLINE SYSTEM THAT INCLUDES SNAP TRANSACTIONS, SNAP DOLLAR AMOUNT, DOUBLE UP FOOD BUCKS (DUFB) DISTRIBUTED, AND DUFB REDEEMED. THE POINT-OF-SALE SYSTEMS TRACK THE DATA WHICH IS TIED TO THE ELIGIBILITY OUTLINED IN THE CONTRACT. PART III, COLUMN (B)-THE NUMBER OF RECIPIENTS IS ESTIMATED USING A NATIONALLY RECOGNIZED FORMULA FOR THE PROGRAM. THE TOTAL ASSISTANCE PROVIDED IS DIVIDED BY AN AVERAGE PURCHASE AMOUNT OF $26.60 PER HOUSEHOLD RECIPIENT.
Schedule I (Form 990) 2019



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