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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
GASTON MEMORIAL HOSPITAL INC
 
Employer identification number
56-0619359
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) KINTEGRA HEALTH
991 WEST HUDSON BLVD
GASTONIA,NC28052
58-1958398 501(C)(3) 176,226 0     COMMUNITY ASSISTANCE
(2) GASTON COUNTY SCHOOLS
PO BOX 1397
GASTONIA,NC280531397
56-6001032 GOVERNMENTAL 76,000 0     COMMUNITY ASSISTANCE
(3) HEALTHNET GASTON
200 EAST FRANKLIN BLVD
GASTONIA,NC28052
56-1913112 501(C)(3) 75,000 0     COMMUNITY ASSISTANCE
(4) GASTON TOGETHER
P O BOX 817
GASTONIA,NC28053
56-2048064 501(C)(3) 32,000 0     COMMUNITY ASSISTANCE
(5) MONTCROSS AREA CHAMBER OF COMMERCE
PO BOX 368
BELMONT,NC28012
56-0710166 501(C)(6) 19,460 0     COMMUNITY ASSISTANCE
(6) HEART SOCIETY OF GASTON COUNTY INC (E-PA
1201 EAST GARRISON BLVD
GASTONIA,NC28054
56-1330921 501(C)(3) 15,000 0     COMMUNITY ASSISTANCE
(7) CANCER SERVICES OF GASTON COUNTY INC
306 SOUTH COLUMBIA ST
GASTONIA,NC28054
56-1164253 501(C)(3) 13,883 0     COMMUNITY ASSISTANCE
(8) GASTON COUNTY FAMILY YMCA
201 SOUTH CLAY STREET
GASTONIA,NC28052
56-0655420 501(C)(3) 11,000 0     COMMUNITY ASSISTANCE
(9) UNITED WAY
P O BOX 2597
GASTONIA,NC28052
56-0653356 501(C)(3) 10,480 0     COMMUNITY ASSISTANCE
(10) BOYS AND GIRLS CLUB OF GREATER GASTON
PO BOX 23
GASTONIA,NC28053
56-1419498 501(C)(3) 10,000 0     COMMUNITY ASSISTANCE
(11) CITY OF MOUNT HOLLY
PO BOX 406
MOUNT HOLLY,NC28120
56-6001295 GOVERNMENTAL 10,000 0     COMMUNITY ASSISTANCE
(12) GASTON COMMUNITY FOUNDATION
1201 E GARRISON BLVD
GASTONIA,NC28053
58-1340834 501(C)(3) 110,000 0     COMMUNITY ASSISTANCE
(13) MEDASSIST OF MECKLENBURG
4428 TAGGART CREEK RD SUITE 101
CHARLOTTE,NC282085400
56-2018957 501(C)(3) 7,500 0     COMMUNITY ASSISTANCE
(14) CITY OF BESSEMER CITY
125 EAST VIRGINA AVE
BESSEMER CITY,NC28016
56-6001177 GOVERNMENTAL 7,000 0     COMMUNITY ASSISTANCE
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Graphic Arrow
17
3
Enter total number of other organizations listed in the line 1 table ........................ . Graphic Arrow
2
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)
(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: OTHER ORGANIZATIONS THAT RECEIVE GRANT FUNDS MAY BE REQUIRED TO SUBMIT MONTHLY REPORTS THAT ARE MONITORED BY MANAGEMENT AND/OR THE BOARD OF DIRECTORS. ALL GRANTS DECISIONS ARE DOCUMENTED.
SCHEDULE I, PART III THE PURPOSE OF THE GERTRUDE CLINTON HEALTH CAREERS SCHOLARSHIP IS TO ENCOURAGE MEDICAL AND HEALTH-RELATED PROFESSIONALS IN THE FIELD OF HUMAN SERVICES TO PRACTICE THEIR SPECIALTIES AT CAROMONT REGIONAL MEDICAL CENTER OR IN GASTON COUNTY.
Schedule I (Form 990) 2021



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