Page 63

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 63 Section 433.54 for all donations.

Donor(s)

Community Health Workers Project The donor(s) for the community health worker project are as follows:

Houston Endowment, Inc. – Jesse and Mary Gibbs Jones established the Houston Endowment, Inc. in 1937 to provide financial support for charitable and educational projects in the Houston community. The total award is $173,000 over a three-year period.

Donor Sources of Revenue

Community Health Workers Project

According to Financial Statements for the Year ended December 31, 2002, it is assured that the Houston Endowment, Inc. receives no more than 25 percent of its annual revenues from health care related providers and does not provide medical or administrative related services under SCHIP.

Funding Flow

Community Health Workers Project Donations will flow from the donor entity (the Houston Endowment, Inc.) to HHSC, which in turn will reflect the amount of those donations in its federal funds claims.

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Page 63

Official source

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 63 Section 433.54 for all donations.

Donor(s)

Community Health Workers Project The donor(s) for the community health worker project are as follows:

Houston Endowment, Inc. – Jesse and Mary Gibbs Jones established the Houston Endowment, Inc. in 1937 to provide financial support for charitable and educational projects in the Houston community. The total award is $173,000 over a three-year period.

Donor Sources of Revenue

Community Health Workers Project

According to Financial Statements for the Year ended December 31, 2002, it is assured that the Houston Endowment, Inc. receives no more than 25 percent of its annual revenues from health care related providers and does not provide medical or administrative related services under SCHIP.

Funding Flow

Community Health Workers Project Donations will flow from the donor entity (the Houston Endowment, Inc.) to HHSC, which in turn will reflect the amount of those donations in its federal funds claims.