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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.
Graphic Arrow Attach to Form 990.
Graphic Arrow Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2021
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) UW SCHOOL OF DENTISTRY
BOX 357137
SEATTLE,WA98195 		94-3079432 501(C)(3) 753,302 0     UNDERWRITE WREB FEES
(2) NORTH SOUND
1204 RAILROAD AVE
BELLINGHAM,WA98225 		81-4680689 501(C)(3) 217,152 0     FUNDING FOR DENTAL SUPPORT
(3) AGING IN PACE WASHINGTON
PO BOX 3007
SEATTLE,WA981143007 		81-0856014 501(C)(3) 200,000 0     FUNDING FOR DENTAL SUPPORT
(4) COMMUNITY HEALTH ASSOCIATION OF SPOKANE
611 NORTH IRON BRIDGE WAY
SPOKANE,WA99111 		91-1641797 501(C)(3) 150,000 0     FUNDING FOR DENTAL SUPPORT
(5) LHAQ'TEMISH FOUNDATIONS
2665 KWINA RD
BELLINGHAM,WA98226 		91-1836621 501(C)(3) 128,000 0     FUNDING FOR DENTAL SUPPORT
(6) LINDQUIST CLINIC FOR CHILDREN
130 131ST ST SOUTH
TACOMA,WA98444 		91-0615378 501(C)(3) 100,000 0     FUNDING FOR DENTAL SUPPORT
(7) BETTER HEALTH TOGETHER
1023 W RIVERSIDE
SPOKANE,WA99201 		90-0997482 501(C)(3) 78,000 0     LEAD PARTNER FUNDING FOR SPOKANE LIN
(8) UNITED WAY OF KING COUNTY
720 SECOND AVE
SEATTLE,WA98104 		91-0565555 501(C)(3) 72,522 0     ANNUAL GIVING CAMPAIGN
(9) FRONTIER BEHAVIORAL HEALTH
107 S DIVISION ST
SPOKANE,WA99202 		91-0853801 501(C)(3) 70,442 0     FUNDING FOR DENTAL SUPPORT
(10) NORTHWEST PORTLAND AREA INDIAN HEALTH BOARD
2121 SW BROADWAY
PORTLAND,OR97201 		93-0718154 501(C)(3) 60,000 0     FUNDING FOR DENTAL SUPPORT
(11) MAKAH TRIBE COUNCIL
PO BOX 115
NEAH BAY,WA98357 		32-0178311   50,000 0     FUNDING FOR DENTAL SUPPORT
(12) EAST AFRICAN COMMUNITY SERVICES
7050 32ND AVE SOUTH
SEATTLE,WA98118 		91-2138852 501(C)(3) 50,000 0     FUNDING FOR DENTAL SUPPORT
(13) MEDICAL TEAMS INTERNATIONAL
9680 153RD AVE NW
REDOMND,WA98052 		93-0878944 501(C)(3) 50,000 0     FUNDING FOR DENTAL SUPPORT
(14) SWINOMISH HEALTH SERVICES (DIDGWALIC WELLNESS CENTER)
8212 S MARCH POINT RD
ANACOSTA,WA98221 		61-1955704   50,000 0     FUNDING FOR DENTAL SUPPORT
(15) UNION GOSPEL MISSION OF YAKIMA
1300 N FIRST STREET
YAKIMA,WA26373 		23-7050061 501(C)(3) 50,000 0     FUNDING FOR DENTAL SUPPORT
(16) AMERICAN ACADEMY OF PEDIATRICS
45 PARK BLVD
ITASCA,IL60143 		36-2275597 501(C)(3) 50,000 0     DENTAL HEALTH GRANT
(17) FREE CLINIC OF SW WASHINGTON
4100 PLOMONDON ST
VANCOUVER,WA94111 		91-1707542 501(C)(3) 50,000 0     FUNDING FOR DENTAL SUPPORT
(18) SPOKANE NEIGHBORHOOD ACTION PARTNERS
3102 W FT GEORGE WRIGHT
SPOKANE,WA99224 		91-1311127 501(C)(3) 44,254 0     FUNDING FOR DENTAL SUPPORT
(19) FOOD LIFELINE
815 SOUTH 96TH
SEATTLE,WA98108 		91-1090450 501(C)(3) 30,081 0     FOOD INSECURITY
(20) LATINO COMMUNITY FUND OF WA STATE
PO BOX 30669
SEATTLE,WA98103 		20-5987399 501(C)(3) 30,000 0     FUNDING FOR DENTAL SUPPORT
(21) ARTS FUND
PO BOX 19780
SEATTLE,WA98109 		91-0839644 501(C)(3) 25,100 0     FUNDING SUPPORT FOR THE ARTS
(22) SQUAXIN ISLAND TRIBE
10 SE SQUAXIN LANE
SHELTON,WA98584 		91-0922254   25,000 0     FUNDING FOR DENTAL SUPPORT
(23) TACOMA PIERCE COUNTY HEALTH DEPARTMENT
3629 SOUTH D STREET
TACOMA,WA96111 		91-1488160 LOCAL GOVERNMENT 18,333 0     FUNDING FOR DENTAL SUPPORT
(24) OLYMPIA UNION GOSPEL MISSION
PO BOX 7668
OLYMPIA,WA985077668 		91-1680748 501(C)(3) 18,186 0     FUNDING FOR DENTAL SUPPORT
(25) SECOND HARVEST FOOD BANK
1234 E FRONT AVE
SPOKANE,WA992022148 		23-7173826 501(C)(3) 15,214 0     FOOD INSECURITY
(26) JUNIOR ACHIEVEMENT OF WASHINGTON
1700 WESTLAKE AVE N
SEATTLE,WA98109 		91-0604913 501(C)(3) 10,750 0     PROGRAM SPONSORSHIP
(27) NORTHWEST HARVEST
PO BOX 12272
SEATTLE,WA98102 		91-0826037 501(C)(3) 10,000 0     FOOD INSECURITY
(28) INTERNATIONAL COMMUNITY HEALTH SERVICES
PO BOX 3007
SEATTLE,WA981143007 		91-0947084 501(C)(3) 10,000 0     FUNDING FOR DENTAL SUPPORT
(29) YOUTH AND FAMILY LINK
907 DOUGLAS ST
LONGVIEW,WA98632 		91-0726260 501(C)(3) 10,000 0     FUNDING FOR DENTAL SUPPORT
(30) UNITED WAY OF KITSAP COUNTY
645 4TH ST SUITE 101
BREMERTON,WA99101 		91-0623990 501(C)(3) 8,000 0     MOUTHMATTERS/ABCD COLLABORATIVE
(31) COMMUNITIES IN SCHOOLS OF SPOKANE COUNTY
104 S FREYAYELLOW FLAG B
SPOKANE,WA99202 		26-1581358 501(C)(3) 5,904 0     2021 SPOKANE LIN GRANT AGREEMENT
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Graphic Arrow
32
3
Enter total number of other organizations listed in the line 1 table ........................ . Graphic Arrow
4
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2021
Page 2

Schedule I (Form 990) 2021
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) COVID-19 PRACTICE SUPPORT GRANTS 2589 2,402,368      
(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: 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 PART III PRSP PAYMENT -IN JULY DDWA APPROVED AN ADDITIONAL COVID-19 PRACTICE SUPPORT PAYMENT FOR WDS MEMBER PRACTICES ENROLLED IN ELECTRONIC FUNDS TRANSFER (EFT) TO HELP DENTISTS OFFSET THE ONGOING THE BUSINESS CHALLENGES THEY ARE EXPERIENCING DURING THE COVID PANDEMIC. PAYMENT WAS MADE SEPTEMBER 27TH AND TOTALED APPROXIMATELY $2.4M. DATA WAS GATHERED THROUGH A JOINT EFFORT BETWEEN FINANCE AND BUSINESS INTELLIGENCE.
Schedule I (Form 990) 2021



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