IRS Form 990-PF for 2009 - Blue Shield of California Foundation

California Physicians' Service Fdn
(dba Blue Shield of California Fdn)
FEIN: 94-2822302
Attachment E
Blue Shield of California Foundation
FEIN 94-2822302
ATTACHMENT TO 2009 FORM 990-PF
RETURN OF PRIVATE FOUNDATION
STATEMENT REQUIRED BY REG. §53.4945-5(d)
INFORMATION WITH RESPECT TO EXPENDITURE RESPONSIBILITY GRANTS
(1) Grantee:
West Contra Costa Healthcare District
2000 Vale Rd
San Pablo, CA 94806
(2) Grant Amount:
$20,000
Date of Grant:
6/1/2008
(3) Purpose:
To enhance and improve the Quality/Infection Prevention and Control Department's
program which has a goal of eliminating hospital acquired infections.
(4) Total Paid:
$10,000 paid on 7/16/2008
$10,000 paid on 12/2/2009
TOTAL $20,000
Amount of Grant Spent by Grantee:
$5,522.08
(5) Diversion:
To the knowledge of the Foundation, and based on the report furnished by the grantee,
no grant funds have been diverted from the purpose of the grant.
(6) Date of Report(s) Received from Grantee:
1/12/2009
9/28/2009
5/5/2010
(7) Verification
Blue Shield of California Foundation reviewed the grant reports received but did not
undertake any verification of the grantee's reports as there has not been any reason to
doubt their accuracy or reliability (Reg. 53.4945-5(c)).
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