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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
Amethyst Place Inc
 
Employer identification number
43-1887442
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)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Graphic Arrow
 
3
Enter total number of other organizations listed in the line 1 table ........................ . Graphic Arrow
 
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) Rental Assistance 161 491,648 74,812 na na
(2) PantryHousehold Assistance 720 5,238 74,812 FMV Food and household goods
(3) Educational Assistance 20 3,309 9,250 na na
(4) Childcare and Support 18 1,234 9,250 na na
(5) Clothing 36 2,145 9,250 na na
(6) Gift Cards 34 200 9,250 Cost Gift Cards
(7) Incentives for Attendence 2 200 36,700 na na
(8) Insurance 3 394 36,700 na na
(9) LegalCourt FeesFines 10 3,848 36,700 na na
(10) Medical Dental Glasses Perscriptions 22 698 36,700 na na
(11) Family Activity Passes 69 3,311 36,700 na na
(12) Transportation gas cards & car repair 69 11,088 36,700 na na
(13) Utility Assistance 6 899 36,700 na na
(14) Furniture and Furnishings 80 7,635 36,700 FMV Furniture and Furnishings
(15) Insurance 3 394 6,856 na na
(16) Diapers 24 1,232 6,856 FMV Diapers
(17) Other Assistance 3 1,232   na na
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
Monitoring procedures (Part I, line 2) The Organization provides assistance to clients and graduates and maintains accounting detail of the amount and type of assistance provided to clients. The Organization does not provide grants.
Schedule I (Form 990) 2021



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