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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
2020
Open to Public
Inspection
Name of the organization
Agnesian Healthcare Inc
 
Employer identification number
39-0807236
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) Boys and Girls Club of Fond du Lac
76 West 2nd Street
Fond du Lac,WI54936 		39-1896496 501(c)(3) 60,000       General support
(2) Downtown Fond du Lac Partnership Inc
131 S MAIN STREET SUITE 101
Fond du Lac,WI54935 		46-1169019 501(c)(3) 8,000       General support
(3) Family Resource Center of Fond du Lac Inc
525 E DIVISION ST STE 109
Fond du Lac,WI54935 		39-1297284 501(c)(3) 10,000       General support
(4) Fond du Lac County Health Department
160 S Macy Street
Fond du Lac,WI54935 		39-6005696 Government 70,000       General support
(5) Fond du Lac Family YMCA
90 W SECOND ST
Fond du Lac,WI54935 		39-0806436 501(c)(3) 25,000       General support
(6) Fond du Lac Literacy Services
32 SHEBOYGAN ST
Fond du Lac,WI54935 		39-1901303 501(c)(3) 10,000       General support
(7) Fond du Lac School District
72 West 9th Street
Fond du Lac,WI54935 		39-1411371 Government 75,000       General support
(8) Marian University
45 SOUTH NATIONAL AVENUE
Fond du Lac,WI54935 		39-1024723 501(c)(3) 307,500       General support
(9) The Regents of the University of California
120 Theory Suite 200
Irvine,CA92697 		95-2226406 Government 15,500       General support
(10) Children's Museam of Fond du Lac
75 West Scott Street
Fond du Lac,WI54935 		56-2471187 501(c)(3) 20,000       General support
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
10
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) 2020
Page 2

Schedule I (Form 990) 2020
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 Procedures for monitoring use of grant funds. THE PROCEDURES USED TO MONITOR THE USE OF GRANT FUNDING VARIES BASED ON THE GRANT RECIPIENT. GRANTS TO RELATED ENTITIES ARE MONITORED DIRECTLY BY THE ORGANIZATION WHEREBY THE RECIPIENT REPORTS ON THE SPECIFIC USE OF THE FUNDING. FOR GRANTS TO UNRELATED ENTITIES, THE ORGANIZATION UTILIZES THE COMMUNITY BENEFIT INVENTORY FOR SOCIAL ACCOUNTABILITY (CBISA) TO TRACK, STORE AND REPORT A WIDE RANGE OF INFORMATION RELATED TO GRANTS AND OVERALL COMMUNITY IMPACT.
Schedule I (Form 990) 2020



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