Form990-PF
Click to see attachment

Department of the Treasury
Internal Revenue Service
Return of Private Foundation
or Section 4947(a)(1) Nonexempt Charitable Trust
Treated as a Private Foundation
Note. The foundation may be able to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0052
2010
For calendar year 2010, or tax year beginning 01-01-2010 , and ending 12-31-2010
G
Check all that apply:
Name of foundation
KOSCIUSKO 21ST CENTURY FOUNDATION INC
 

Number and street (or P.O. box number if mail is not delivered to street address)2170 N POINTE DRIVE   Room/suite
City or town, state, and ZIP code
WARSAW, IN465182814
A Employer identification number

35-1187105
B Telephone number (see page 10 of the instructions)

(574) 269-5188
C bullet
D 1. bullet
H Check type of organization:
2. bullet
I Fair market value of all assets at end
of year (from Part II, col. (c),
line 16)bullet$64,585,167J Accounting method:
 
(Part I, column (d) must be on cash basis.)
E bullet
F bullet
Part I Analysis of Revenue and Expenses (The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see page 11 of the instructions).) (a) Revenue and
expenses per
books 		(b) Net investment
income 		(c) Adjusted net
income 		(d) Disbursements
for charitable
purposes
(cash basis only)
Revenue 1 Contributions, gifts, grants, etc., received (attach schedule) 220,858
2 Check bullet
3 Interest on savings and temporary cash investments 935,612 935,612  
4 Dividends and interest from securities...... 610,095 610,095  
5a Gross rents..............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 2,797,275
b Gross sales price for all assets on line 6a 28,596,288
7 Capital gain net income (from Part IV, line 2)... 2,797,275
8 Net short-term capital gain.........  
9 Income modifications...........  
10a Gross sales less returns and allowances  
b Less: Cost of goods sold....  
c Gross profit or (loss) (attach schedule).....    
11 Other income (attach schedule)....... Click to see attachment 12,246 12,246 0
12 Total. Add lines 1 through 11........ 4,576,086 4,355,228 0
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 140,846 0 0 140,846
14 Other employee salaries and wages...... 63,038 0 0 62,763
15 Pension plans, employee benefits....... 34,428 0 0 34,428
16a Legal fees (attach schedule)......... Click to see attachment 1,552 0 0 1,552
b Accounting fees (attach schedule)....... Click to see attachment 26,678 0 0 26,678
c Other professional fees (attach schedule).... Click to see attachment 273,587 273,587 0 0
17 Interest...............        
18 Taxes (attach schedule) (see page 14 of the instructions) Click to see attachment 91,544 9,548 0 0
19 Depreciation (attach schedule) and depletion... 24,528 0 0
20 Occupancy.............. 56,602 0 0 56,602
21 Travel, conferences, and meetings....... 8,849 0 0 8,849
22 Printing and publications.......... 7,503 0 0 7,503
23 Other expenses (attach schedule)....... Click to see attachment 58,643 0 0 58,166
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 787,798 283,135 0 397,387
25 Contributions, gifts, grants paid........ 2,495,858 2,430,737
26 Total expenses and disbursements. Add lines 24 and 25 3,283,656 283,135 0 2,828,124
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements 1,292,430
b Net investment income (if negative, enter -0-) 4,072,093
c Adjusted net income (if negative, enter -0-)... 0
For Privacy Act and Paperwork Reduction Act Notice, see page 30 of the instructions.
Cat. No. 11289X Form 990-PF (2010)
Form 990-PF (2010)
Page 2
Part II Balance Sheets Attached schedules and amounts in the description column
should be for end-of-year amounts only. (See instructions.)		 Beginning of year End of year
(a) Book Value (b) Book Value (c) Fair Market Value
Assets 1 Cash—non-interest-bearing...............      
2 Savings and temporary cash investments.......... 2,718,209 7,952,120 7,952,120
3 Accounts receivable bullet  
Less: allowance for doubtful accounts bullet        
4 Pledges receivable bullet  
Less: allowance for doubtful accounts bullet        
5 Grants receivable.................      
6 Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see page 15 of the
instructions)....................      
7 Other notes and loans receivable (attach schedule) bullet  
Less: allowance for doubtful accounts bullet        
8 Inventories for sale or use...............      
9 Prepaid expenses and deferred charges........... 22,676 5,441 5,441
10a Investments—U.S. and state government obligations (attach schedule) 10,571,936 Click to see attachment11,318,484 11,628,992
b Investments—corporate stock (attach schedule)........ 31,937,764 Click to see attachment31,927,393 38,032,507
c Investments—corporate bonds (attach schedule)........      
11 Investments—land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
12 Investments—mortgage loans..............      
13 Investments—other (attach schedule)........... 6,225,000 Click to see attachment1,795,000 1,795,000
14 Land, buildings, and equipment: basis bullet404,291
Less: accumulated depreciation (attach schedule) bullet198,790 243,331 Click to see attachment205,501 205,501
15 Other assets (describe bullet) Click to see attachment5,078,351 Click to see attachment4,965,606 Click to see attachment4,965,606
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 56,797,267 58,169,545 64,585,167
Liabilities 17 Accounts payable and accrued expenses.......... 5,221 10,913
18 Grants payable................... 368,819 433,940
19 Deferred revenue..................    
20 Loans from officers, directors, trustees, and other disqualified persons    
21 Mortgages and other notes payable (attach schedule)......    
22 Other liabilities (describe bullet) Click to see attachment39,153 Click to see attachment70,271
23 Total liabilities (add lines 17 through 22).......... 413,193 515,124
Net Assets or Fund Balances bullet
and complete lines 24 through 26 and lines 30 and 31.
24 Unrestricted.................... 56,174,835 57,418,217
25 Temporarily restricted................ 209,239 236,204
26 Permanently restricted................    
bullet
and complete lines 27 through 31.
27 Capital stock, trust principal, or current funds.........    
28 Paid-in or capital surplus, or land, bldg., and equipment fund    
29 Retained earnings, accumulated income, endowment, or other funds    
30 Total net assets or fund balances (see page 17 of the
instructions).................... 56,384,074 57,654,421
31 Total liabilities and net assets/fund balances (see page 17 of
the instructions).................. 56,797,267 58,169,545
Part III Analysis of Changes in Net Assets or Fund Balances
1 Total net assets or fund balances at beginning of year—Part II, column (a), line 30 (must agree
with end-of-year figure reported on prior year’s return)............... 1 56,384,074
2 Enter amount from Part I, line 27a...................... 2 1,292,430
3 Other increases not included in line 2 (itemize) bullet 3 0
4 Add lines 1, 2, and 3.......................... 4 57,676,504
5 Decreases not included in line 2 (itemize) bulletClick to see attachment 5 22,083
6 Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 30.. 6 57,654,421
Form 990-PF (2010)
Form 990-PF (2010)
Page 3
Part IV
Capital Gains and Losses for Tax on Investment Income
(a) List and describe the kind(s) of property sold (e.g., real estate,
2-story brick warehouse; or common stock, 200 shs. MLC Co.) 		(b) How acquired
P—Purchase
D—Donation 		(c) Date acquired
(mo., day, yr.) 		(d) Date sold
(mo., day, yr.)
1 a SALE OF SECURITIES      
b SALE OF LAND P    
c
d
e
(e) Gross sales price (f) Depreciation allowed
(or allowable) 		(g) Cost or other basis
plus expense of sale 		(h) Gain or (loss)
(e) plus (f) minus (g)
a 28,575,847   25,785,712 2,790,135
b 20,441   13,301 7,140
c
d
e
Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69 (l) Gains (Col. (h) gain minus
col. (k), but not less than -0-) or
Losses (from col.(h))
(i) F.M.V. as of 12/31/69 (j) Adjusted basis
as of 12/31/69 		(k) Excess of col. (i)
over col. (j), if any
a       2,790,135
b       7,140
c
d
e
2 Capital gain net income or (net capital loss) Bracket If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7		 Bracket 2 2,797,275
3 Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
If gain, also enter in Part I, line 8, column (c) (see pages 13 and 17 of the instructions).
If (loss), enter -0- in Part I, line 8 . . . . . . . . . . . . . 		Bracket 3  
Part V
Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income
(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.)

If section 4940(d)(2) applies, leave this part blank.
Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period?
If “Yes,” the foundation does not qualify under section 4940(e). Do not complete this part.
1 Enter the appropriate amount in each column for each year; see page 18 of the instructions before making any entries.
(a)
Base period years Calendar
year (or tax year beginning in) 		(b)
Adjusted qualifying distributions 		(c)
Net value of noncharitable-use assets 		(d)
Distribution ratio
(col. (b) divided by col. (c))
2009 2,796,031 49,230,579 0.056795
2008 2,362,515 60,602,843 0.038984
2007 3,432,117 70,312,443 0.048812
2006 2,710,562 67,189,136 0.040342
2005 2,793,245 62,750,755 0.044513
2 Total of line 1, column (d) ...................... 2 0.229446
3 Average distribution ratio for the 5-year base period—divide the total on line 2 by 5, or by
the number of years the foundation has been in existence if less than 5 years. . . 		3 0.045889
4 Enter the net value of noncharitable-use assets for 2010 from Part X, line 5..... 4 54,610,094
5 Multiply line 4 by line 3....................... 5 2,506,003
6 Enter 1% of net investment income (1% of Part I, line 27b)........... 6 40,721
7 Add lines 5 and 6......................... 7 2,546,724
8 Enter qualifying distributions from Part XII, line 4.............. 8 3,268,558
If line 8 is equal to or greater than line 7, check the box in Part VI, line 1b, and complete that part using a 1% tax rate. See
the Part VI instructions on page 18.
Form 990-PF (2010)
Form 990-PF (2010)
Page 4
Part VI
Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see page 18 of the instructions)
1a Bulletand enter “N/A” on line 1. Bracket
Date of ruling or determination letter:   (attach copy of letter if necessary–see instructions)
b 1 40,721
hereBulletand enter 1% of Part I, line 27b...................
c All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part I, line 12, col. (b)
2 Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 2 0
3 Add lines 1 and 2............................ 3 40,721
4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-). 4 0
5 Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- ..... 5 40,721
6 Credits/Payments:
a 2010 estimated tax payments and 2009 overpayment credited to 2010 6a 35,233
b Exempt foreign organizations—tax withheld at source....... 6b
c Tax paid with application for extension of time to file (Form 8868) 6c  
d Backup withholding erroneously withheld ........... 6d  
7 Total credits and payments. Add lines 6a through 6d.............. 7 35,233
8 Enter any penalty for underpayment of estimated tax. if Form 2220 is attached. 8  
9 Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......Bullet 9 5,488
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...Bullet 10  
11 Enter the amount of line 10 to be: Credited to 2011 estimated taxBullet   Refunded Bullet 11  
Part VII-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign? ....................
1a
 
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes (see page 19 of
the instructions for definition)?.............................
1b
 
No
If the answer is “Yes” to 1a or 1b, attach a detailed description of the activities and copies of any materials
published or distributed by the foundation in connection with the activities.
c
Did the foundation file Form 1120-POL for this year?.....................
1c
 
No
d
Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1) On the foundation. bullet$ 0(2) On foundation managers.bullet$ 0
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.bullet$ 0
2
Has the foundation engaged in any activities that have not previously been reported to the IRS?.......
2
 
No
If “Yes,” attach a detailed description of the activities.
3
Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles
of incorporation, or bylaws, or other similar instruments? If “Yes,” attach a conformed copy of the changes....
3
 
No
4a
Did the foundation have unrelated business gross income of $1,000 or more during the year?........
4a
 
No
b
If “Yes,” has it filed a tax return on Form 990-T for this year?...................
4b
 
 
5
Was there a liquidation, termination, dissolution, or substantial contraction during the year?.........
5
 
No
If “Yes,” attach the statement required by General Instruction T.
6
Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either:
  • By language in the governing instrument, or
  • By state legislation that effectively amends the governing instrument so that no mandatory directions
    • that conflict with the state law remain in the governing instrument?................
    6
    Yes
     
    7
    Did the foundation have at least $5,000 in assets at any time during the year? If “Yes,” complete Part II, col. (c), and Part XV.
    7
    Yes
     
    8a
    Enter the states to which the foundation reports or with which it is registered (see page 19 of the
    instructions)bulletIN
    b
    If the answer is “Yes” to line 7, has the foundation furnished a copy of Form 990-PF to the Attorney
    General (or designate) of each state as required by General Instruction G? If “No,” attach explanation .
    8b
    Yes
     
    9
    Is the foundation claiming status as a private operating foundation within the meaning of section 4942(j)(3)
    or 4942(j)(5) for calendar year 2010 or the taxable year beginning in 2010 (see instructions for Part XIV on
    page 27)? If “Yes,” complete Part XIV...........................
    9
     
    No
    10
    Did any persons become substantial contributors during the tax year? If “Yes,” attach a schedule listing their names and addresses.
    10
     
    No
    11
    At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the
    meaning of section 512(b)(13)? If "Yes," attach schedule. (see page 20 of the instructions) .......
    11
     
    No
    12
    Did the foundation acquire a direct or indirect interest in any applicable insurance contract before August 17, 2008?
    12
     
    No
    13
    Did the foundation comply with the public inspection requirements for its annual returns and exemption application?
    13
    Yes
     
    Website addressbulletWWW.K21FOUNDATION.ORG
    14
    The books are in care ofbulletRICH HADDAD Telephone no.bullet (574) 269-5188
    Located atbullet2170 N POINTE DRIVEWARSAWIN ZIP+4bullet465182814
    15
    Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041.........bullet
    and enter the amount of tax-exempt interest received or accrued during the year ......bullet
    15  
    16
    At any time during calendar year 2010, did the foundation have an interest in or a signature or other authority over
    a bank, securities, or other financial account in a foreign country? .................
    16
     
    No
    See page 20 of the instructions for exceptions and filing requirements for Form TD F 90-22.1. If "Yes", enter the name of the foreign country bullet  
    Form 990-PF (2010)
    Form 990-PF (2010)
    Page 5
    Part VII-B
    Statements Regarding Activities for Which Form 4720 May Be Required
    File Form 4720 if any item is checked in the “Yes” column, unless an exception applies.
    Yes
    No
    1a
    During the year did the foundation (either directly or indirectly):
    (1) Engage in the sale or exchange, or leasing of property with a disqualified person?
    (2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from)
    a disqualified person?.........................
    (3) Furnish goods, services, or facilities to (or accept them from) a disqualified person?
    (4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person?
    (5) Transfer any income or assets to a disqualified person (or make any of either available
    for the benefit or use of a disqualified person)?.................
    (6) Agree to pay money or property to a government official? (Exception. Check “No”
    if the foundation agreed to make a grant to or to employ the official for a period
    after termination of government service, if terminating within 90 days.).........
    b
    If any answer is “Yes” to 1a(1)–(6), did any of the acts fail to qualify under the exceptions described in Regulations
    section 53.4941(d)-3 or in a current notice regarding disaster assistance (see page 20 of the instructions)?...
    1b
     
     
    .........bullet
    c
    Did the foundation engage in a prior year in any of the acts described in 1a, other than excepted acts,
    that were not corrected before the first day of the tax year beginning in 2010?.............
    1c
     
    No
    2
    Taxes on failure to distribute income (section 4942) (does not apply for years the foundation was a private
    operating foundation defined in section 4942(j)(3) or 4942(j)(5)):
    a
    At the end of tax year 2010, did the foundation have any undistributed income (lines 6d
    and 6e, Part XIII) for tax year(s) beginning before 2010?...............
    If “Yes,” list the years bullet20, 20, 20, 20
    b
    Are there any years listed in 2a for which the foundation is not applying the provisions of section 4942(a)(2)
    (relating to incorrect valuation of assets) to the year’s undistributed income? (If applying section 4942(a)(2)
    to all years listed, answer “No” and attach statement—see page 20 of the instructions.) .........
    2b
     
     
    c
    If the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here.
    bullet20, 20, 20, 20
    3a
    Did the foundation hold more than a 2% direct or indirect interest in any business
    enterprise at any time during the year?.....................
    b
    If “Yes,” did it have excess business holdings in 2010 as a result of (1) any purchase by the foundation
    or disqualified persons after May 26, 1969; (2) the lapse of the 5-year period (or longer period approved
    by the Commissioner under section 4943(c)(7)) to dispose of holdings acquired by gift or bequest; or (3)
    the lapse of the 10-, 15-, or 20-year first phase holding period? (Use Schedule C, Form 4720, to determine
    if the foundation had excess business holdings in 2010.)....................
    3b
     
     
    4a
    Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes?
    4a
     
    No
    b
    Did the foundation make any investment in a prior year (but after December 31, 1969) that could jeopardize its
    charitable purpose that had not been removed from jeopardy before the first day of the tax year beginning in 2010?
    4b
     
    No
    5a
    During the year did the foundation pay or incur any amount to:
    (1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))?
    (2) Influence the outcome of any specific public election (see section 4955); or to carry
    on, directly or indirectly, any voter registration drive?...............
    (3) Provide a grant to an individual for travel, study, or other similar purposes?
    (4) Provide a grant to an organization other than a charitable, etc., organization described
    in section 509(a)(1), (2), or (3), or section 4940(d)(2)? (see page 22 of the instructions)...
    (5) Provide for any purpose other than religious, charitable, scientific, literary, or
    educational purposes, or for the prevention of cruelty to children or animals?........
    b
    If any answer is “Yes” to 5a(1)–(5), did any of the transactions fail to qualify under the exceptions described in
    Regulations section 53.4945 or in a current notice regarding disaster assistance (see page 22 of the instructions)?
    5b
     
     
    .........bullet
    c
    If the answer is “Yes” to question 5a(4), does the foundation claim exemption from the
    tax because it maintained expenditure responsibility for the grant?............
    If “Yes,” attach the statement required by Regulations section 53.4945–5(d).
    6a
    Did the foundation, during the year, receive any funds, directly or indirectly, to pay
    premiums on a personal benefit contract?....................
    b
    Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract?....
    6b
     
    No
    If “Yes” to 6b, file Form 8870.
    7a
    At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction?
    b
    If yes, did the foundation receive any proceeds or have any net income attributable to the transaction? ....
    7b
     
     
    Form 990-PF (2010)
    Form 990-PF (2010)
    Page 6
    Part VIII
    Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
    and Contractors
    1 List all officers, directors, trustees, foundation managers and their compensation (see page 22 of the instructions).
    (a) Name and address (b) Title, and average
    hours per week
    devoted to position     		(c) Compensation
     (If not paid, enter
    -0-)     		(d) Contributions to
    employee benefit plans
    and deferred compensation     		(e) Expense account,
    other allowances
    RICHARD HADDAD PRESIDENT
    40.00     		140,846 4,194 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    GEORGE W GILBERT CHAIRMAN
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    JON SROUFE VICE CHAIRMAN
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    LEE HEYDE TREASURER
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    MARIE TRUMP SECRETARY
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    JOSEPH BANKS DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    KAREN BOLING DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    SHARI BOYLE DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    KEN DAVIDSON DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    DAVID DICK DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    BECKY DOLL DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    DAVID HAINES DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    JOE HAWN DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    ROSY JANSMA DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    JENNIFER LUCHT DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    DENNIS REEVE DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    JAMES TINKEY DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    VALERIE WARNER DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    2 Compensation of five highest-paid employees (other than those included on line 1—see page 23 of the instructions).
    If none, enter “NONE.”
    (a) Name and address of each employee paid more than $50,000 (b) Title, and average
    hours per week
    devoted to position     		(c) Compensation (d) Contributions to
    employee benefit
    plans and deferred
    compensation     		(e) Expense account,
    other allowances
    NONE
    Total number of other employees paid over $50,000...................bullet 0
    3 Five highest-paid independent contractors for professional services (see page 23 of the instructions). If none, enter "NONE".
    (a) Name and address of each person paid more than $50,000 (b) Type of service (c) Compensation
    NONE
    Total number of others receiving over $50,000 for professional services.............bullet0
    Part IX-A
    Summary of Direct Charitable Activities
    List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc. Expenses
    1
     
    2  
    3  
    4  
    Form 990-PF (2010)
    Form 990-PF (2010)
    Page 7
    Part IX-B
    Summary of Program-Related Investments (see page 23 of the instructions)
    Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2. Amount
    1 LOAN TO KOSCIUSKO HEALTH SERVICES PAVILION, INC. A SECTION 501(C)(3) ORGANIZATION. 437,571
    2 LOAN TO HARVEST WITH A HEART, INC. A SECTION 501(C)(3) ORGANIZATION. 2,863
    All other program-related investments. See page 24 of the instructions.
    3  
    Total. Add lines 1 through 3...........................bullet440,434
    Part X
    Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations,
    see page 24 of the instructions.)
    1
    Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,
    purposes:
    a
    Average monthly fair market value of securities...................
    1a
    50,179,598
    b
    Average of monthly cash balances.......................
    1b
    5,262,122
    c
    Fair market value of all other assets (see page 24 of the instructions)............
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    55,441,720
    e
    Reduction claimed for blockage or other factors reported on lines 1a and
    1c (attach detailed explanation) ..............
    1e
    0
    2
    Acquisition indebtedness applicable to line 1 assets..................
    2
    0
    3
    Subtract line 2 from line 1d..........................
    3
    55,441,720
    4
    Cash deemed held for charitable activities. Enter 1 1⁄2% of line 3 (for greater amount, see page 25
    of the instructions) ............................
    4
    831,626
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    54,610,094
    6
    Minimum investment return. Enter 5% of line 5...................
    6
    2,730,505
    Part XI
    Distributable Amount bullet and do not complete this part.)
    1
    Minimum investment return from Part X, line 6....................
    1
    2,730,505
    2a
    Tax on investment income for 2010 from Part VI, line 5......
    2a
    40,721
    b
    Income tax for 2010. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    40,721
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    2,689,784
    4
    Recoveries of amounts treated as qualifying distributions................
    4
    0
    5
    Add lines 3 and 4.............................
    5
    2,689,784
    6
    Deduction from distributable amount (see page 25 of the instructions)...........
    6
    0
    7
    Distributable amount as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII,
    line 1.................................
    7
    2,689,784
    Part XII
    Qualifying Distributions (see page 25 of the instructions)
    1
    Amounts paid (including administrative expenses) to accomplish charitable, etc., purposes:
    a
    Expenses, contributions, gifts, etc.—total from Part I, column (d), line 26 ..........
    1a
    2,828,124
    b
    Program-related investments—total from Part IX-B..................
    1b
    440,434
    2
    Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
    purposes................................
    2
     
    3
    Amounts set aside for specific charitable projects that satisfy the:
    a
    Suitability test (prior IRS approval required)....................
    3a
     
    b
    Cash distribution test (attach the required schedule) .................
    3b
     
    4
    Qualifying distributions. Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
    4
    3,268,558
    5
    Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment
    income. Enter 1% of Part I, line 27b (see page 26 of the instructions)............
    5
    40,721
    6
    Adjusted qualifying distributions. Subtract line 5 from line 4...............
    6
    3,227,837
    Note: The amount on line 6 will be used in Part V, column (b), in subsequent years when calculating whether the foundation qualifies for
    the section 4940(e) reduction of tax in those years.
    Form 990-PF (2010)
    Form 990-PF (2010)
    Page 8
    Part XIII
    Undistributed Income (see page 26 of the instructions)
    (a)
    Corpus     		(b)
    Years prior to 2009     		(c)
    2009     		(d)
    2010
    1 Distributable amount for 2010 from Part XI, line 7 2,689,784
    2 Undistributed income, if any, as of the end of 2010:
    a Enter amount for 2009 only....... 1,975,885
    b Total for prior years:20, 20, 20 0
    3 Excess distributions carryover, if any, to 2010:
    a From 2005.......  
    b From 2006.......  
    c From 2007.......  
    d From 2008.......  
    e From 2009.......  
    fTotal of lines 3a through e......... 0
    4Qualifying distributions for 2010 from Part
    XII, line 4: bullet$ 3,268,558
    a Applied to 2009, but not more than line 2a 1,975,885
    b Applied to undistributed income of prior years
    (Election required—see page 26 of the instructions)    		 0
    c Treated as distributions out of corpus (Election
    required—see page 26 of the instructions)...     		0
    d Applied to 2010 distributable amount..... 1,292,673
    e Remaining amount distributed out of corpus 0
    5 Excess distributions carryover applied to 2010. 0 0
    (If an amount appears in column (d), the
    same amount must be shown in column (a).)
    6Enter the net total of each column as
    indicated below:
    a Corpus. Add lines 3f, 4c, and 4e. Subtract line 5 0
    b Prior years’ undistributed income. Subtract
    line 4b from line 2b ...........     		0
    c Enter the amount of prior years’ undistributed
    income for which a notice of deficiency has
    been issued, or on which the section 4942(a)
    tax has been previously assessed......     		0
    d Subtract line 6c from line 6b. Taxable
    amount—see page 27 of the instructions ...     		0
    e Undistributed income for 2009. Subtract line
    4a from line 2a. Taxable amount—see page 27
    of the instructions ...........     		0
    f Undistributed income for 2010. Subtract
    lines 4d and 5 from line 1. This amount must
    be distributed in 2011 ..........     		1,397,111
    7 Amounts treated as distributions out of
    corpus to satisfy requirements imposed by
    section 170(b)(1)(F) or 4942(g)(3) (see page 27
    of the instructions) ...........     		0
    8Excess distributions carryover from 2005 not
    applied on line 5 or line 7 (see page 27 of the
    instructions) .............     		0
    9Excess distributions carryover to 2011.
    Subtract lines 7 and 8 from line 6a ......     		0
    10 Analysis of line 9:
    a Excess from 2006....  
    b Excess from 2007....  
    c Excess from 2008....  
    d Excess from 2009....  
    e Excess from 2010....  
    Form 990-PF (2010)
    Form 990-PF (2010)
    Page 9
    Part XIV
    Private Operating Foundations (see page 27 of the instructions and Part VII-A, question 9)
    1a If the foundation has received a ruling or determination letter that it is a private operating
    foundation, and the ruling is effective for 2010, enter the date of the ruling.......bullet
     
    b Check box to indicate whether the organization is a private operating foundation described in section or
    2a Enter the lesser of the adjusted net
    income from Part I or the minimum
    investment return from Part X for each
    year listed ..........     		Tax year Prior 3 years (e) Total
    (a) 2010 (b) 2009 (c) 2008 (d) 2007
             
    b 85% of line 2a .........          
    c Qualifying distributions from Part XII,
    line 4 for each year listed .....     		         
    d Amounts included in line 2c not used directly
    for active conduct of exempt activities ....     		         
    e Qualifying distributions made directly
    for active conduct of exempt activities.
    Subtract line 2d from line 2c ....     		         
    3 Complete 3a, b, or c for the
    alternative test relied upon:
    a “Assets” alternative test—enter:
    (1) Value of all assets ......          
    (2) Value of assets qualifying
    under section 4942(j)(3)(B)(i)    		          
    b “Endowment” alternative test— enter 2⁄3
    of minimum investment return shown in
    Part X, line 6 for each year listed...     		         
    c “Support” alternative test—enter:
    (1) Total support other than gross
    investment income (interest,
    dividends, rents, payments
    on securities loans (section
    512(a)(5)), or royalties) ....     		         
    (2) Support from general public
    and 5 or more exempt
    organizations as provided in
    section 4942(j)(3)(B)(iii)....     		         
    (3) Largest amount of support
    from an exempt organization    		          
    (4) Gross investment income          
    Part XV
    Supplementary Information (Complete this part only if the organization had $5,000 or more in
    assets at any time during the year—see page 27 of the instructions.)
    1Information Regarding Foundation Managers:
    aList any managers of the foundation who have contributed more than 2% of the total contributions received by the foundation
    before the close of any tax year (but only if they have contributed more than $5,000). (See section 507(d)(2).)
    bList any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
    ownership of a partnership or other entity) of which the foundation has a 10% or greater interest.
    2Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
    Check here bullet
    aThe name, address, and telephone number of the person to whom applications should be addressed:
    KOSCIUSKO 21ST CENTURY FOUNDATION I
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    (574) 269-5188
    bThe form in which applications should be submitted and information and materials they should include:
    PREDOMINANTLY MOST GRANTS USE THE SAME STANDARD FORM WITH THE APPLICATION STATING FOR WHAT THE AMOUNT IS BEING ASKED AND FOR WHAT PURPOSE THE GRANT MONIES WILL BE USED.
    cAny submission deadlines:
    VARIOUS DEADLINES SET
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    SOME OF THE GRANTS ARE CONDITIONAL GRANTS MEANING THE GRANTEE MUST PERFORM CERTAIN PREREQUISITES BEFORE MONIES ARE GRANTED.
    Form 990-PF (2010)
    Form 990-PF (2010)
    Page 10
    Part XV
    Supplementary Information (continued)
    3 Grants and Contributions Paid During the Year or Approved for Future Payment
    Recipient If recipient is an individual,
    show any relationship to
    any foundation manager
    or substantial contributor
    		 Foundation
    status of
    recipient     		Purpose of grant or
    contribution     		Amount
    Name and address (home or business)
    aPaid during the year
    BIG BROTHERS BIG SISTERS
    2349 FAIRFIELD AVENUE
    FORT WAYNE,IN46807     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 5,000
    BOWEN CENTER
    850 NORTH HARRISON ST
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 9,000
    CANCER SERVICES OF NORTHEAST INDIANA
    6316 MUTUAL DRIVE
    FORT WAYNE,IN46825     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 14,500
    CARDINAL SERVICES INC
    504 NORTH BAY DRIVE
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 20,250
    CITY OF WARSAW FBO WARSAW FIRE DEPT
    PO BOX 817
    WARSAW,IN46581     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 3,000
    FAMILY CHRISTIAN DEVELOPMENT CENTER
    PO BOX 227
    NAPPANEE,IN46550     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 10,000
    HISPANICLATINO HEALTH COALITION
    323 STOCKER COURT
    ELKHART,IN46516     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 8,300
    KOSCIUSKO COUNTY COMMUNITY FOUNDATION
    102 EAST MARKET STREET
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 150,000
    KOSCIUSKO HOME CARE & HOSPICE
    1515 PROVIDENT DR STE 250
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 280,200
    MAD ANTHONY'S CHILDREN'S HOPE HOUSE
    7922 WEST JEFFERSON BLVD
    FORT WAYNE,IN46804     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 15,000
    STRYKER FINANCE
    4664 CAMPUS DRIVE STE 130
    KALAMAZOO,MI49008     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 9,000
    WARSAW COMMUNITY SCHOOLS
    PO BOX 288
    WARSAW,IN46581     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 10,000
    CANCER CARE GRANTS - VARIOUS
    PO BOX 1809
    WARSAW,IN46518     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 192,893
    BOBCAT OF WARSAW
    3568 S SR 15
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 12,375
    CLIFFS & CABLES LLC
    1424 W WELLINGTON AVE
    CHICAGO,IL60657     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 54,785
    DIMENSION FORD NORTH
    310 W COLISEUM BOULEVARD
    FORT WAYNE,IN46805     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 20,000
    DISCOUNT SCHOOL SUPPLY
    PO BOX 6013
    CAROL STREAM,IL601976013     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,819
    DOUG OGLE
    1206 RANCH ROAD
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 3,680
    EARLY CHILDHOOD ALLIANCE
    3320 FAIRFIELD AVE
    FORT WAYNE,IN46807     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 7,500
    EDUCATIONAL FURNITURE
    620 E 18TH ST
    MUNCIE,IN47302     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 2,850
    EMERGENY MEDICAL PRODUCTS
    406 RELIABLE PKWY
    CHICAGO,IL606860044     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 3,268
    FARMTEK
    1395 JOHN FITCH BLVD
    SOUTH WINDSOR,CT06074     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 4,284
    FIRE SERVICE INC
    9545 INDUSTRIAL DRIVE NORTH
    ST JOHN,IN46373     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 24,039
    FIREHOUSE RESOURCES LLC
    100 LN 890 C SNOW LAKE
    FREMONT,IN46737     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 25,000
    G & G HAULING & EXCAVATING
    115 N COLUMBIA ST
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 15,078
    GENE A MYERS
    16925 CR 146
    NEW PARIS,IN46553     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 2,908
    GOPHER
    PO BOX 998
    OWATONNA,MN550600998     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,117
    GOSHEN FLOOR MART
    65669 US 33
    GOSHEN,IN46526     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,597
    GRACE COLLEGE & SEMINARY
    200 SEMINARY DRIVE
    WINONA LAKE,IN46590     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 35,524
    HAMMAN CONCRETE & EXCAVATING INC
    PO BOX 1624
    WARSAW,IN46581     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 20,100
    HASKINE UNDERGROUND INC
    8111 9B ROAD
    PLYMOUTH,IN46563     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 10,000
    HEALTH CONNECT
    1515 PROVIDENT DR STE 240
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 66,306
    HEARTLINE PREGNANCY CENTER
    1515 PROVIDENT DR STE 180
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 25,865
    HISPANICLATINO HEALTH COALITION
    323 STOCKER COURT
    ELKHART,IN46516     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 13,651
    HOUSING OPPORTUNITIES OF WARSAW
    827 SOUTH UNION ST STE 230
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 26,742
    INDIANA YOUTH RUGBY FOUNDATION
    26 EMS T34A LANE
    LEESBURG,IN46538     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,500
    INTERNATIONAL MULCH COMPANY
    1 MULCH LANE
    ST LOUIS,MO63044     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 3,851
    IVY TECH FOUNDATION
    220 DEAN JOHNSON BLVD
    SOUTH BEND,IN46601     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 121,523
    KLINE EXCAVATING
    418 SOUTH SYCAMORE ST
    SYRACUSE,IN46567     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,000
    KOSCIUSKO COUNTY COMMUNITY FOUNDATION
    102 E MARKET ST
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 75,000
    KOSCIUSKO COUNTY HEALTH DEPARTMENT
    100 W CENTER ST 3RD FLOOR
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 96,024
    KOSCIUSKO HOME CARE & HOSPICE
    1515 PROVIDENT DRIVE STE 250
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 207,146
    LIFELINE YOUTH & FAMILY SERVICES
    PO BOX 80487
    FORT WAYNE,IN468980487     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 29,780
    LOWE'S
    2495 JALYNN STREET
    WARSAW,IN46582     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 5,984
    MCMILLEN CENTER FOR HEALTH EDUCATION
    600 JIM KELLEY BLVD
    FORT WAYNE,IN46816     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 20,225
    MEDCO SPORTS MEDICINE
    500 FILLMORE AVE
    TONAWANDA,NY14150     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 3,006
    MID-AMERICA SPORTS ADVANTAGE
    1413 S MERIDIAN RD
    JASPER,IN47546     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 17,842
    REESE RECREATION PRODUCTS INC
    3327 NORTH RIDGE AVE
    ARLINGTON HEIGHTS,IL600041488     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,259
    RICHARD RIDER ELECTRIC INC
    PO BOX 521
    COLUMBIA CITY,IN46725     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,746
    RUICH BROS IRRIGATION CORP
    7124 GOSHEN RD
    FORT WAYNE,IN46818     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 10,262
    SNIDER & ASSOCIATES
    10139 ROYALTON ROAD STE H
    NORTH ROYALTON,OH44133     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 18,995
    SOCIETY OF ST ANDREW
    3383 SWEET HOLLOW RD
    BIG ISLAND,VA245263054     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 3,019
    TEE'S PLUS
    PO BOX 81
    BRATTLEBORO,VT05302     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 4,688
    WHITKO COMMUNITY SCHOOL CORP
    PO BOX 114
    PIERCETON,IN46562     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 19,818
    OTHER CONDITIONAL GRANTS 1000
    2170 N POINTE DRIVE
    WARSAW,IN46518     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 9,351
    AMERICAN DIABETES ASSOCIATION
    6415 CASTLEWAY WEST DR STE 114
    INDIANAPOLIS,IN46250     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,000
    BAKER YOUTH CLUB
    765 W MARKET ST
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,000
    BEAMAN HOME
    PO BOX 12
    WARSAW,IN46581     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,000
    BODKIN ABSTRACT
    122 W MAIN ST
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 5,719
    CARDMEMBER SERVICE
    PO BOX 790408
    ST LOUIS,MO631790408     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 5,035
    CAREY BUILDING MAINTENANCE LLC
    PO BOX 534
    SOUTH WHITLEY,IN46787     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 3,576
    CITY OF WARSAW
    117 EAST CANAL ST
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 2,100
    COMM TO COMMEMORATE DR MARTIN L KING
    202 E CENTER ST
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,000
    HALL RENDER KILLIAN HEATH & LYMAN PC
    39778 TREASURY CENTER
    CHICAGO,IL606949700     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 23,313
    HARMONY MARKETING GROUP
    115 NORTH MAIN ST
    BOURBON,IN46504     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,240
    KOSCIUSKO COUNTY ANIMAL SHELTER
    3489 E 100 S
    WARSAW,IN46582     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,500
    KOSCIUSKO COUNTY COMMUNITY FOUNDATION
    102 E MARKET ST
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 51,500
    KOSCIUSKO HEALTH SERVICES PAVILION INC
    1515 PROVIDENT DR
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 560,571
    MENTONE ELEMENTARY SCHOOL
    PO BOX 457
    MENTONE,IN46539     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,000
    NORTH WEBSTER DAYCARE
    PO BOX 316
    NORTH WEBSTER,IN46555     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,000
    NORTHSTAR MEDICAL EQUIPMENT
    1241 RIDGE CREEK TRAIL
    ADA,MI49301     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 2,888
    SALVATION ARMY
    501 ARTHUR ST
    WARSAW,IN46580     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,100
    TOWN OF PIERCETON
    PO BOX 496
    PIERCETON,IN46562     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 1,000
    OTHER DIRECT TO EXPENSE GRANTS 1000
    2170 N POINTE DRIVE
    WARSAW,IN46518     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 7,545
    Total .................................bullet 3a 2,430,737
    bApproved for future payment
    OTHER UNCONDITIONAL GRANTS
    2170 N POINTE DRIVE
    WARSAW,IN46518     		NONE   TO SUPPORT STATED PURPOSE OF GRANT REQUEST 65,121
    Total ..................................bullet 3b 65,121
    Form 990-PF (2010)
    Form 990-PF (2010)
    Page 11
    Part XVI-A
    Analysis of Income-Producing Activities
    Enter gross amounts unless otherwise indicated. Unrelated business income Excluded by section 512, 513, or 514 (e)
    Related or exempt
    function income
    (See page 28 of
    the instructions.)
    1Program service revenue: (a)
    Business code     		(b)
    Amount     		(c)
    Exclusion code     		(d)
    Amount
    a
    b
    c
    d
    e
    f
    gFees and contracts from government agencies          
    2 Membership dues and assessments....          
    3Interest on savings and temporary cash investments     14 935,612  
    4 Dividends and interest from securities....     14 610,095  
    5 Net rental income or (loss) from real estate:
    aDebt-financed property......          
    bNot debt-financed property.....          
    6Net rental income or (loss) from personal property          
    7 Other investment income.....     14 12,246  
    8Gain or (loss) from sales of assets other than inventory     18 2,797,275  
    9 Net income or (loss) from special events:          
    10 Gross profit or (loss) from sales of inventory..          
    11 Other revenue: a
    b
    c
    d
    e
    12 Subtotal. Add columns (b), (d), and (e).. 0 4,355,228 0
    13Total. Add line 12, columns (b), (d), and (e)...................
    134,355,228
    (See worksheet in line 13 instructions on page 28 to verify calculations.)
    Part XVI-B
    Relationship of Activities to the Accomplishment of Exempt Purposes
    Line No.
    DownArrow     		Explain below how each activity for which income is reported in column (e) of Part XVI-A contributed importantly to
    the accomplishment of the organization’s exempt purposes (other than by providing funds for such purposes). (See
    page 28 of the instructions.)
    Form 990-PF (2010)
    Form 990-PF (2010)
    Page 12
    Part XVII
    Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations
    1
    Did the organization directly or indirectly engage in any of the following with any other organization described in section
    Yes
    No
    501(c) of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political organizations?
    a
    Transfers from the reporting foundation to a noncharitable exempt organization of:
    (1) Cash....................................
    1a(1)
     
    No
    (2) Other assets.................................
    1a(2)
     
    No
    b
    Other transactions:
    (1) Sales of assets to a noncharitable exempt organization....................
    1b(1)
     
    No
    (2) Purchases of assets from a noncharitable exempt organization..................
    1b(2)
     
    No
    (3) Rental of facilities, equipment, or other assets.......................
    1b(3)
     
    No
    (4) Reimbursement arrangements............................
    1b(4)
     
    No
    (5) Loans or loan guarantees..............................
    1b(5)
     
    No
    (6) Performance of services or membership or fundraising solicitations................
    1b(6)
     
    No
    c
    Sharing of facilities, equipment, mailing lists, other assets, or paid employees..............
    1c
     
    No
    d
    If the answer to any of the above is “Yes,” complete the following schedule. Column (b) should always show the fair market value
    of the goods, other assets, or services given by the reporting foundation. If the foundation received less than fair market value
    in any transaction or sharing arrangement, show in column (d) the value of the goods, other assets, or services received.
    (a) Line No. (b) Amount involved (c) Name of noncharitable exempt organization (d) Description of transfers, transactions, and sharing arrangements
    2a
    Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations
    described in section 501(c) of the Code (other than section 501(c)(3)) or in section 527?...........
    b
    If “Yes,” complete the following schedule.
    (a) Name of organization (b) Type of organization (c) Description of relationship
    SignHere
    Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer or fiduciary) is based on all information of which preparer has any knowledge.
    Bullet Bullet
    Signature of officer or trustee Date Title
    PaidPreparersUseOnly Preparer's SignatureBullet Date PTIN
    Firm's namebullet



    Firm's addressbullet







         		Firm's EINbullet
    Phone no.
    Form 990-PF (2010)
    Additional Data


    Software ID:  
    Software Version:  


    Form 990PF - Special Condition Description:
    Special Condition Description
    Schedule B
    (Form 990, 990-EZ,
    or 990-PF)
    Department of the Treasury
    Internal Revenue Service
    Schedule of Contributors
    Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
    OMB No. 1545-0047
    2010
    Name of organization
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
     
    Employer identification number

    35-1187105
    Organization type (check one):
    Filers of:
    Section:
    Form 990 or 990-EZ





    Form 990-PF




    Check if your organization is covered by the General Rule or a Special Rule.  
    Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
    General Rule—
    Special Rules
    ......................... Arrow Bullet   $    
    Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
    990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990, or check the box in the heading of its
    Form 990-EZ, or on line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
    990-EZ, or 990-PF).
    For Paperwork Reduction Act Notice, see the Instructions
    for Form 990, 990-EZ, or 990-PF.
    Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2010)

    Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
    Page 1 of 1 of Part I
    Name of organization
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
          		Employer identification number

    35-1187105
    Part I
    Contributors (see Instructions)
    		     
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Aggregate contributions    		 (d)
    Type of contribution
    1
    K21 HEALTH FOUNDATION
     

         
    PO BOX 1810
       
    WARSAW, IN   46581

    		$10,000




    (Complete Part II if there is
    a noncash contribution.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Aggregate contributions    		 (d)
    Type of contribution
    2
    WAGON WHEEL PRODUCTIONS
     

         
    PO BOX 804
       
    WARSAW, IN   46581

    		$7,943




    (Complete Part II if there is
    a noncash contribution.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Aggregate contributions    		 (d)
    Type of contribution
    3
    MICHAEL HIMES
     

         
    142 EMS T53 LN
       
    LEESBURG, IN   46538

    		$6,580




    (Complete Part II if there is
    a noncash contribution.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Aggregate contributions    		 (d)
    Type of contribution
    4
    RANDY KIRKENDALL
     

         
    10 STONECAMP TRAIL
       
    WINONA LAKE, IN   46590

    		$5,049




    (Complete Part II if there is
    a noncash contribution.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Aggregate contributions    		 (d)
    Type of contribution
    5
    DEPUY PRODUCTS INC
     

         
    700 ORTHOPAEDIC DR
       
    WARSAW, IN   46580

    		$5,000




    (Complete Part II if there is
    a noncash contribution.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Aggregate contributions    		 (d)
    Type of contribution
     
     
     

         
     
       

    		$  




    (Complete Part II if there is
    a noncash contribution.)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

    Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
    Page 1 of 1 of Part II
    Name of organization
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
          		Employer identification number

    35-1187105
    Part II
    Noncash Property (see Instructions)
    		     
    (a) No.
    from
    Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (see instructions)     		(d)
    Date received
     
    		$    
    (a) No.
    from
    Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (see instructions)     		(d)
    Date received
     
    		$    
    (a) No.
    from
    Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (see instructions)     		(d)
    Date received
     
    		$    
    (a) No.
    from
    Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (see instructions)     		(d)
    Date received
     
    		$    
    (a) No.
    from
    Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (see instructions)     		(d)
    Date received
     
    		$    
    (a) No.
    from
    Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (see instructions)     		(d)
    Date received
     
    		$    
    Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

    Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
    Page 1 of 1 of Part III
    Name of organization
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
          		Employer identification number

    35-1187105
    Part III
    Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
    aggregating more than $1,000 for the year. (Complete columns (a) through (e) and the following line entry.)
    For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
    contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
    (a) No.
    from
    Part I    		 (b)
    Purpose of gift    		 (c)
    Use of gift    		 (d)
    Description of how gift is held
     
    (e)
    Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
           
     
    (a) No.
    from
    Part I    		 (b)
    Purpose of gift    		 (c)
    Use of gift    		 (d)
    Description of how gift is held
     
    (e)
    Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
           
     
    (a) No.
    from
    Part I    		 (b)
    Purpose of gift    		 (c)
    Use of gift    		 (d)
    Description of how gift is held
     
    (e)
    Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
           
     
    (a) No.
    from
    Part I    		 (b)
    Purpose of gift    		 (c)
    Use of gift    		 (d)
    Description of how gift is held
     
    (e)
    Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
           
     
    Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

    Additional Data


    Software ID:  
    Software Version:  

    TY 2010 AccountingFeesSchedule
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
    EIN: 35-1187105
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    ACCOUNTING FEES 26,678 0 0 26,678

    TY 2010 GeneralExplanationAttachment
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
    EIN: 35-1187105
    Identifier Return Reference Explanation
    MISSION STATEMENT FORM 990 K21 HEALTH FOUNDATION EXISTS FOR THE BENEFIT OF KOSCIUSKO COUNTY CITIZENS TO ENSURE HEALTH CARE SERVICES ARE PROVIDED, AND TO ADVANCE PREVENTION AND HEALTHY LIFESTYLES. THIS WILL BE ACCOMPLISHED BY IDENTIFYING HEALTH NEEDS IN OUR COMMUNITY AND MAINTAINING AN ENDOWMENT SO FUNDING IS AVAILABLE, THROUGH INVESTMENTS AND GRANTS, FOR THOSE NEEDS.
    CANCER CARE FUND FORM 990 THE KOSCIUSKO COUNTY CANCER CARE FUND, ADMINISTERED BY K21 HEALTH FOUNDATION, WAS ESTABLISHED FOR THE PURPOSE OF PROVIDING FINANCIAL ASSISTANCE TO CITIZENS OF KOSCIUSKO COUNTY WHO FIND THEMSELVES IN NEED DUE TO A CANCER DIAGNOSIS. TO QUALIFY FOR ASSISTANCE, A RECIPIENT MUST PROVIDE VERIFICATION FROM A MEDICAL DOCTOR SHOWING A DIAGNOSIS OF CANCER. THE RECIPIENTS MUST ALSO SHOW THAT THEY ARE INCURRING COSTS AS A RESULT OF THEIR ILLNESS.IN NEARLY ALL SITUATIONS, FINANCIAL ASSISTANCE IS PAID DIRECTLY TO A VENDOR ON BEHALF OF THE CLIENTS. THE CANCER FUND SOCIAL WORKER REVIEWS ALL CASES AND COLLABORATES WITH ONE OR MORE MEMBERS OF THE NINE-PERSON CANCER CARE COMMITTEE TO AUTHORIZE PAYMENTS FROM THE FUND.

    TY 2010 InvestmentsCorpStockSchedule
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
    EIN: 35-1187105
    Name of Stock End of Year Book Value End of Year Fair Market Value
    EQUITY SECURITIES 31,927,393 38,032,507

    TY 2010 InvestmentsGovtObligationsSch
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
    EIN: 35-1187105
    US Government Securities - End of Year Book Value:

    11,318,484
    US Government Securities - End of Year Fair Market Value:

    11,628,992
    State & Local Government Securities - End of Year Book Value:


    0
    State & Local Government Securities - End of Year Fair Market Value:


    0


    TY 2010 InvestmentsOtherSchedule2
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
    EIN: 35-1187105
    Category/ Item Listed at Cost or FMV Book Value End of Year Fair Market Value
    CERTIFICATES OF DEPOSIT AT COST 1,795,000 1,795,000

    TY 2010 LandEtcSchedule2
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
    EIN: 35-1187105
    Category / Item Cost / Other Basis Accumulated Depreciation Book Value End of Year Fair Market Value
    LAND 7,140 0 7,140 7,140
    OFFICE & COMPUTER EQUIPMENT 71,830 31,637 40,193 40,193
    BUILDINGS 325,321 167,153 158,168 158,168


    TY 2010 LegalFeesSchedule
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
    EIN: 35-1187105
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    LEGAL FEES 1,552 0 0 1,552


    TY 2010 OtherAssetsSchedule
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
    EIN: 35-1187105
    Description Beginning of Year - Book Value End of Year - Book Value End of Year - Fair Market Value
    PROPERTY HELD FOR GRANT MAKING 5,078,351 0 0
    NOTES RECIEVABLE HELD FOR GRANT MAKING 0 4,965,606 4,965,606


    TY 2010 OtherDecreasesSchedule
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
    EIN: 35-1187105
    Description Amount
    2010 MARKET VALUE TO BOOK VALUE ADJUSTMENT 22,083


    TY 2010 OtherExpensesSchedule
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
    EIN: 35-1187105
    Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    INSURANCE 6,557 0 0 6,080
    MARKETING 30,398 0 0 30,398
    MISCELLANEOUS EXPENSE 21,688 0 0 21,688


    TY 2010 OtherIncomeSchedule2
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
    EIN: 35-1187105
    Description Revenue And Expenses Per Books Net Investment Income Adjusted Net Income
    OTHER INCOME 12,246 12,246  


    TY 2010 OtherLiabilitiesSchedule
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
    EIN: 35-1187105
    Description Beginning of Year - Book Value End of Year - Book Value
    DEFERRED TAX LIABILITY 39,153 70,271


    TY 2010 OtherProfessionalFeesSchedule
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
    EIN: 35-1187105
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    INVESTMENT MGT FEES 273,587 273,587 0 0


    TY 2010 TaxesSchedule
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
    EIN: 35-1187105
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    EXCISE TAXES 81,768 0 0 0
    FOREIGN INCOME TAXES 9,549 9,548 0 0
    PROPERTY TAXES 227 0 0 0