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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
Mountain States Health Alliance
dba Johnson City Medical Center
Employer identification number
62-0476282
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) Childrens Advocacy Center
201 E Myrtle Avenue
Johnson City,TN37601 		62-1765785 501c3 10,000 0     Sponsorship
(2) East Tennessee State Univ
P O Box 70732
Johnson City,TN37614 		62-6021046   1,775,000 0     Rural Health Research
(3) International Storytelling Cn
100 W Main Street
Jonesborough,TN37659 		62-1014756 501c3 8,000 0     Sponsorship
(4) Isaiah 117 House
PO Box 842
Elizabethton,TN37644 		82-0631497 501c3 25,000 0     Sponsorship
(5) Music For All
39 W Jckson Place Suite 150
Indianapolis,IN46225 		36-3413042 501c3 9,000 0     Sponsorship
(6) Town of Pennington Gap
PO Box 305
Pennington Gap,VA24277 		54-6015001   6,000 0     Sponsorship
(7) US of Care
1110 Vermont Ave NW Suite 950
Washington,DC20005 		82-2860302 501c3 100,000 0     Healthcare Access
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) 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
Grantmaker's Description of How Grants are Used The Community Benefit and Population Health Committee for Ballad Health is comprised of members from Tennessee and Virginia. Committee members have various perspectives on community health improvement and work to develop an understanding of population health, philanthropy, community benefit obligations and the role Ballad Health plays in health access improvement. The senior leadership for Ballad Health, including the President and CEO and COO, attend the meetings. Among the responsibilities of the committee is ensuring charitable contributions comply with Ballad Health Board policies.All requests are submitted electronically with the required information to determine eligibility. After the committee has reviewed requests, various levels of approval are required, including the Ballad Health CEO or Ballad Health Board, based on the level of commitment. Applicants requesting funding for a specific event or program should include the following information:-Mission statement of organization-Year organization was founded-Tax status and federal taxpayer ID number -Website-Description of the event/program-Event/program budget-Other sources of income-Impact of the event/program on the health of residents in our region-Beneficiaries of contribution-Number of people served annually -Event/program accomplishments-Measure of accomplishments
Schedule I (Form 990) 2019



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