Form990-PF
Click to see attachment

Department of the Treasury
Internal Revenue Service

Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
bulletDo not enter social security numbers on this form as it may be made public.
bulletInformation about Form 990-PF and its instructions is at www.irs.gov/form990pf.
OMB No. 1545-0052
2015
Open to Public Inspection
For calendar year 2015, or tax year beginning 01-01-2015 , and ending 12-31-2015
Name of foundation
Kosciusko 21st Century Foundation Inc
aka K21 Health Foundation
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 or province, country, and ZIP or foreign postal code
Warsaw, IN46582
A Employer identification number

35-1187105
B Telephone number (see instructions)

(574) 269-5188
C bullet
G Check all that apply:

D 1. bullet
2. bullet
E bullet
H Check type of organization:
F bullet
I Fair market value of all assets at end
of year (from Part II, col. (c),
line 16)bullet$69,197,070J Accounting method:
 
(Part I, column (d) must be on cash basis.)
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 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) 250,498
2 Check bullet Sch. B .............
3 Interest on savings and temporary cash investments 554,339 554,339  
4 Dividends and interest from securities... 1,050,011 1,050,011  
5a Gross rents............ 160,829 160,829  
b Net rental income or (loss) 38,942
6a Net gain or (loss) from sale of assets not on line 10 2,642,580
b Gross sales price for all assets on line 6a 45,742,308
7 Capital gain net income (from Part IV, line 2)... 2,642,580
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 2,265 2,265 0
12 Total. Add lines 1 through 11........ 4,660,522 4,410,024 0
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 173,338 0 0 173,338
14 Other employee salaries and wages...... 74,166 0 0 244,701
15 Pension plans, employee benefits....... 25,099 0 0 25,099
16a Legal fees (attach schedule)......... Click to see attachment 480 0 0 480
b Accounting fees (attach schedule)....... Click to see attachment 26,700 0 0 26,700
c Other professional fees (attach schedule).... Click to see attachment 211,444 211,444 0 0
17 Interest...............        
18 Taxes (attach schedule) (see instructions)... Click to see attachment 16,624 0 0 0
19 Depreciation (attach schedule) and depletion... 114,079 109,022 0
20 Occupancy.............. 43,953 0 0 43,953
21 Travel, conferences, and meetings....... 17,417 0 0 17,417
22 Printing and publications.......... 4,572 0 0 4,572
23 Other expenses (attach schedule)....... Click to see attachment 303,942 12,865 0 127,975
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 1,011,814 333,331 0 664,235
25 Contributions, gifts, grants paid....... 3,346,455 3,427,569
26 Total expenses and disbursements. Add lines 24 and 25 4,358,269 333,331 0 4,091,804
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements 302,253
b Net investment income (if negative, enter -0-) 4,076,693
c Adjusted net income (if negative, enter -0-)... 0
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X Form 990-PF (2015)
Form 990-PF (2015)
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......... 1,376,152 865,613 865,613
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 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.......... 7,246 8,473 8,473
10a Investments—U.S. and state government obligations (attach schedule) 5,178,594 Click to see attachment5,922,534 5,883,666
b Investments—corporate stock (attach schedule)....... 33,991,798 Click to see attachment33,820,865 41,331,672
c Investments—corporate bonds (attach schedule)....... 9,704,881 Click to see attachment9,401,571 9,221,904
11 Investments—land, buildings, and equipment: basis bullet1,893,615
Less: accumulated depreciation (attach schedule) bullet238,646 1,763,992 Click to see attachment1,654,969 1,654,969
12 Investments—mortgage loans.............      
13 Investments—other (attach schedule).......... 5,338,895 Click to see attachment5,383,543 6,211,061
14 Land, buildings, and equipment: basis bullet88,993
Less: accumulated depreciation (attach schedule) bullet84,602 9,448 Click to see attachment4,391 4,391
15 Other assets (describe bullet) Click to see attachment3,598,804 Click to see attachment4,015,321 Click to see attachment4,015,321
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 60,969,810 61,077,280 69,197,070
Liabilities 17 Accounts payable and accrued expenses.......... 351 13,762
18 Grants payable.................. 652,311 577,036
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 attachment105,533 Click to see attachment81,198
23 Total liabilities (add lines 17 through 22)......... 758,195 671,996
Net Assets or Fund Balances bullet
and complete lines 24 through 26 and lines 30 and 31.
24 Unrestricted.................. 59,826,489 59,954,698
25 Temporarily restricted............... 385,126 450,586
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 instructions)..... 60,211,615 60,405,284
31 Total liabilities and net assets/fund balances (see instructions). 60,969,810 61,077,280
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
60,211,615
2
Enter amount from Part I, line 27a .....................
2
302,253
3
Other increases not included in line 2 (itemize) bulletClick to see attachment
3
3,444,065
4
Add lines 1, 2, and 3 ..........................
4
63,957,933
5
Decreases not included in line 2 (itemize) bulletClick to see attachment
5
3,552,649
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 30 .
6
60,405,284
Form 990-PF (2015)
Form 990-PF (2015)
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 P    
b
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 45,742,308   43,099,728 2,642,580
b
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       2,642,580
b
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 2,642,580
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 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 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))
2014 3,838,345 67,153,038 0.057158
2013 3,352,218 62,610,514 0.053541
2012 3,002,834 57,062,361 0.052624
2011 3,182,910 57,452,206 0.055401
2010 3,227,837 54,610,094 0.059107
2
Total of line 1, column (d) .....................
20.277831
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
0.055566
4
Enter the net value of noncharitable-use assets for 2015 from Part X, line 5.....
4
66,164,115
5
Multiply line 4 by line 3......................
5
3,676,475
6
Enter 1% of net investment income (1% of Part I, line 27b)...........
6
40,767
7
Add lines 5 and 6........................
7
3,717,242
8
Enter qualifying distributions from Part XII, line 4.............
8
4,250,293
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.
Form 990-PF (2015)
Form 990-PF (2015)
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 Bullet and enter “N/A" on line 1. Bracket
Date of ruling or determination letter:   (attach copy of letter if necessary–see instructions)
b 1 40,767
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 40,767
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 40,767
6 Credits/Payments:
a 2015 estimated tax payments and 2014 overpayment credited to 2015 6a 40,000
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 40,000
8 Enter any penalty for underpayment of estimated tax. if Form 2220 is attached. Click to see attachment 8 81
9 Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......Bullet 9 848
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 2015 estimated taxBullet   RefundedBullet 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 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 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 2015 or the taxable year beginning in 2015 (see instructions for Part XIV)?
    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
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 5
    Part VII-A
    Statements Regarding Activities (continued)
    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 instructions) .............
    11
     
    No
    12
    Did the foundation make a distribution to a donor advised fund over which the foundation or a disqualified person had
    advisory privileges? If "Yes," attach statement (see instructions).................
    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+4bullet46582
    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 2015, did the foundation have an interest in or a signature or other authority over YesNo
    a bank, securities, or other financial account in a foreign country?
    16   No
    See instructions for exceptions and filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR). If "Yes", enter the name of the foreign country bullet  
    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 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 2015?.............
    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 2015, did the foundation have any undistributed income (lines 6d
    and 6e, Part XIII) for tax year(s) beginning before 2015?.............
    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 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 2015 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 2015.)..................
    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 2015?
    4b
     
    No
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 6
    Part VII-B
    Statements Regarding Activities for Which Form 4720 May Be Required (Continued)
    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 4945(d)(4)(A)? (see 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 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 (2015)
    Form 990-PF (2015)
    Page 7
    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 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     		173,338 5,279 0
    2170 North Pointe Drive
    Warsaw,IN46582
    James TINKEY Chairman
    1.00     		0 0 0
    2170 North Pointe Drive
    Warsaw,IN46582
    Scott Tucker Vice Chairman
    1.00     		0 0 0
    2170 North Pointe Drive
    warsaw,IN46582
    Dana Krull Treasurer
    1.00     		0 0 0
    2170 North Pointe Drive
    warsaw,IN46582
    Shari Boyle Secretary
    1.00     		0 0 0
    2170 North Pointe Drive
    warsaw,IN46582
    Becky Alles 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
    Dr David Dick diRECTOR
    1.00     		0 0 0
    2170 North Pointe Drive
    warsaw,IN46582
    Steve Grill DiRECTOR
    1.00     		0 0 0
    2170 North Pointe Drive
    Warsaw,IN46582
    Andrew Grossnickle DIRECTOR
    1.00     		0 0 0
    2170 North Pointe Drive
    warsaw,IN46582
    Dr 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
    Max Mock DiRECTOR
    1.00     		0 0 0
    2170 North Pointe Drive
    Warsaw,IN46582
    Kevin Roberts DiRECTOR
    1.00     		0 0 0
    2170 North Pointe Drive
    warsaw,IN46582
    Steve Ross 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 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 instructions). If none, enter "NONE".
    (a) Name and address of each person paid more than $50,000 (b) Type of service (c) Compensation
    DJ Construction Co Inc General Contractor 283,910
    3414 Elkhart Rd
    Goshen,IN46526
    Niblock Paving contractor 125,000
    PO Box 211
    Bristol,IN46507
    ButtTimmons Construction General Contractor 123,118
    6635 East 950 North
    Syracuse,IN46567
    WJ Carey Construction General Contractor 81,900
    PO Box 534
    South Whitley,IN46787
    Heiman Construction Inc general Contractor 73,420
    1125 Executive Drive
    Warsaw,IN46580
    Total number of others receiving over $50,000 for professional services.............bullet2
    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  
    Part IX-B
    Summary of Program-Related Investments (see instructions)
    Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2. Amount
    1 Forgiveness of current Loan mortgage interest due from Kosciusko Health Services Pavilion, Inc., a section 501(c(3) Organization. 149,900
    2 Forgiveness of current Loan due from Harvest with a Heart, Inc. a section 501(c)(3) Organization. 8,589
    All other program-related investments. See instructions.
    3  
    Total. Add lines 1 through 3.........................bullet158,489
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 8
    Part X
    Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations,see 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
    66,797,603
    b
    Average of monthly cash balances.......................
    1b
    374,087
    c
    Fair market value of all other assets (see instructions)................
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    67,171,690
    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
    67,171,690
    4
    Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
    instructions) .............................
    4
    1,007,575
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    66,164,115
    6
    Minimum investment return. Enter 5% of line 5..................
    6
    3,308,206
    Part XI
    Distributable Amount bullet
    1
    Minimum investment return from Part X, line 6....................
    1
    3,308,206
    2a
    Tax on investment income for 2015 from Part VI, line 5......
    2a
    40,767
    b
    Income tax for 2015. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    40,767
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    3,267,439
    4
    Recoveries of amounts treated as qualifying distributions................
    4
    0
    5
    Add lines 3 and 4............................
    5
    3,267,439
    6
    Deduction from distributable amount (see instructions).................
    6
    0
    7
    Distributable amount as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII, line 1 ...
    7
    3,267,439
    Part XII
    Qualifying Distributions (see 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
    4,091,804
    b
    Program-related investments—total from Part IX-B..................
    1b
    158,489
    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
    4,250,293
    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 instructions).................
    5
    40,767
    6
    Adjusted qualifying distributions. Subtract line 5 from line 4..............
    6
    4,209,526
    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 (2015)
    Form 990-PF (2015)
    Page 9
    Part XIII
    Undistributed Income (see instructions)
    (a)
    Corpus     		(b)
    Years prior to 2014     		(c)
    2014     		(d)
    2015
    1 Distributable amount for 2015 from Part XI, line 7 3,267,439
    2 Undistributed income, if any, as of the end of 2015:
    a Enter amount for 2014 only....... 0
    b Total for prior years:20, 20, 20 0
    3 Excess distributions carryover, if any, to 2015:
    a From 2010......  
    b From 2011......  
    c From 2012......  
    d From 2013......  
    e From 2014...... 87,852
    fTotal of lines 3a through e........ 87,852
    4Qualifying distributions for 2015 from Part
    XII, line 4: bullet$ 4,250,293
    a Applied to 2014, but not more than line 2a 0
    b Applied to undistributed income of prior years
    (Election required—see instructions).....     		0
    c Treated as distributions out of corpus (Election
    required—see instructions)........     		0
    d Applied to 2015 distributable amount..... 3,267,439
    e Remaining amount distributed out of corpus 982,854
    5 Excess distributions carryover applied to 2015. 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 1,070,706
    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 instructions ...........     		0
    e Undistributed income for 2014. Subtract line
    4a from line 2a. Taxable amount—see
    instructions .............     		0
    f Undistributed income for 2016. Subtract
    lines 4d and 5 from line 1. This amount must
    be distributed in 2015 ..........     		0
    7 Amounts treated as distributions out of
    corpus to satisfy requirements imposed by
    section 170(b)(1)(F) or 4942(g)(3) (Election may
    be required - see instructions) .......     		0
    8Excess distributions carryover from 2010 not
    applied on line 5 or line 7 (see instructions) ...     		0
    9Excess distributions carryover to 2016.
    Subtract lines 7 and 8 from line 6a ......     		1,070,706
    10 Analysis of line 9:
    a Excess from 2011....  
    b Excess from 2012....  
    c Excess from 2013....  
    d Excess from 2014.... 87,852
    e Excess from 2015.... 982,854
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 10
    Part XIV
    Private Operating Foundations (see 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 2015, 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) 2015 (b) 2014 (c) 2013 (d) 2012
             
    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 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 or e-mail address 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:
    SEE STATEMENTS 20 AND 21.
    cAny submission deadlines:
    SEE STATEMENTS 20 AND 21.
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    SEE STATEMENTS 20 AND 21.
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 11
    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
    Cancer Care Grant Abby Daugherty
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,542
    Cancer Care Grant Amanda Dickinson
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,615
    Cancer Care Grant Amanda Sudlow
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,974
    Cancer Care Grant Angela Ward
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,888
    Cancer Care Grant Anna Accettura
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 200
    Cancer Care Grant Anthony Gee
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 917
    Cancer Care Grant Bill Robertson
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 75
    Cancer Care Grant Bradley Trostle
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,475
    Cancer Care Grant Brenda Bowers
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,500
    Cancer Care Grant Brenda Roberts
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 525
    Cancer Care Grant Bryan Foreman
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,000
    Cancer Care Grant Catherine Hawkins
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 433
    Cancer Care Grant Charles Fletcher
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 728
    Cancer Care Grant Charles Gibson
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,500
    Cancer Care Grant Chester Clampitt
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,698
    Cancer Care Grant Cindy Bolin
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 267
    Cancer Care Grant David Burgess
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,000
    Cancer Care Grant Deanna Smith
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 400
    Cancer Care Grant DeWayne Creamer
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,519
    Cancer Care Grant Diana Bailey
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 47
    Cancer Care Grant Diana Goans
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 25
    Cancer Care Grant Dianna Baker
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,503
    Cancer Care Grant Dianna Heisler
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 875
    Cancer Care Grant Eldred Ehmen
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 782
    Cancer Care Grant Elizabeth Malagon
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 129
    Cancer Care Grant Eusebio Malagon
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 402
    Cancer Care Grant Fred Hewitt
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,511
    Cancer Care Grant Garin Voorheis
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,000
    Cancer Care Grant Georgina Mitchell
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,933
    Cancer Care Grant Henrietta Meyer
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,458
    Cancer Care Grant Irene Smith
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,900
    Cancer Care Grant Isaac Crow
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,500
    Cancer Care Grant James Fiorucci
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 100
    Cancer Care Grant Janet Hofer
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,000
    Cancer Care Grant Jannel Eakright
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,487
    Cancer Care Grant Jason Bodley
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 7,262
    Cancer Care Grant Jason Schmidt
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,838
    Cancer Care Grant Jay Horn
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 200
    Cancer Care Grant Jeff Beaverson
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,562
    Cancer Care Grant Jeffery Beaverson
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 930
    Cancer Care Grant Jeni Fisher
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,375
    Cancer Care Grant Jeremy Blackburn
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 63
    Cancer Care Grant Jesse Hurley
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 500
    Cancer Care Grant Jett Roe
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,297
    Cancer Care Grant Jewell Sausaman
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 963
    Cancer Care Grant Johnny Isaac
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 302
    Cancer Care Grant Joyce McCleese
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,518
    Cancer Care Grant Judith Childers
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 500
    Cancer Care Grant Judy Childers
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,000
    Cancer Care Grant Julia Youst
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 486
    Cancer Care Grant Karleen Richards
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 360
    Cancer Care Grant Kathy McElroy
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,211
    Cancer Care Grant Kathy Reynolds
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 100
    Cancer Care Grant Kenneth Farmer
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,350
    Cancer Care Grant Leo Richey
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 250
    Cancer Care Grant Leslie Carnes
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,360
    Cancer Care Grant Linda Fletcher
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 500
    Cancer Care Grant Linda Novotny
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 50
    Cancer Care Grant Mandy Dickinson
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 876
    Cancer Care Grant Margarita Maldona
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 725
    Cancer Care Grant Marilyn Braddock
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,517
    Cancer Care Grant Marshal Crawford
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 223
    Cancer Care Grant Martha Allen
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 296
    Cancer Care Grant Mary Geisleman
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 400
    Cancer Care Grant Mary Isaac
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 25
    Cancer Care Grant Mary Joyner
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 252
    Cancer Care Grant Mary Kern
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,000
    Cancer Care Grant Mary Potts
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,500
    Cancer Care Grant Mary Wadkins
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 457
    Cancer Care Grant Melody May
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,000
    Cancer Care Grant Michelle Baker
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,000
    Cancer Care Grant Mike Williamson
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 310
    Cancer Care Grant Mitchell Dulworth
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 585
    Cancer Care Grant Naoma Foreman
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,498
    Cancer Care Grant Nathan Dolbee
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 500
    Cancer Care Grant Patricia Keim
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,490
    Cancer Care Grant Peggy Stamper
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 50
    Cancer Care Grant Rhonda Phillips
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 100
    Cancer Care Grant Rita Sabo
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 450
    Cancer Care Grant Robert Bloom
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 179
    Cancer Care Grant Roberto Cervantes
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,730
    Cancer Care Grant Robin Evans
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 500
    Cancer Care Grant Ronald Ashby
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 485
    Cancer Care Grant Ronald Konkle
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 5,500
    Cancer Care Grant Ronald Miller
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 902
    Cancer Care Grant Russell Bailey
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 229
    Cancer Care Grant Ryan Owen
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 641
    Cancer Care Grant Sandra Tuncil
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 394
    Cancer Care Grant Shirley Owens
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 305
    Cancer Care Grant Susan Gerrity
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,969
    Cancer Care Grant Tammy Martin
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,200
    Cancer Care Grant Teo Xique
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,887
    Cancer Care Grant Tim Frame
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,334
    Cancer Care Grant Vicki Randall
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 423
    Cancer Care Grant Vickie Tolson
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 161
    Cancer Care Grant Walter Larue
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,600
    Cancer Care Grant Willie Fields
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,843
    Cancer Care Grant Wilma Justice
    PO Box 1810
    Warsaw,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,761
    UNCONDITIONAL GRANT Baker Youth Club
    1401 E Smith St
    Warsaw,IN46580     		NONE PC Summer Fitness Program 27,000
    UNCONDITIONAL GRANT Big Brothers Big Sisters
    2349 Fairfield Avenue
    Fort Wayne,IN46807     		NONE PC Stop Sexual Abuse Training 5,000
    UNCONDITIONAL GRANT Brightpoint
    227 E Washington Blvd
    Fort Wayne,IN46804     		NONE PC Operational Assistance 15,000
    UNCONDITIONAL GRANT Cancer Services of Northeast Indiana
    6316 Mutual Drive
    Fort Wayne,IN46825     		NONE PC Direct Assistance / Client Advocacy 15,000
    UNCONDITIONAL GRANT Combined Community Services
    1195 Mariners Dr
    Warsaw,IN46582     		NONE PC Project Independence 6,460
    UNCONDITIONAL GRANT Erin's House for Grieving Children
    5670 YMCA Park Drvie West
    Fort Wayne,IN46835     		NONE PC Operational Assistance 10,000
    UNCONDITIONAL GRANT Heartline Pregnancy Center
    1515 Provident Drive
    Warsaw,IN46580     		NONE PC Mobile Unit Operations 45,000
    UNCONDITIONAL GRANT Joe's Kids
    3540 Commerci Dr
    Warsaw,IN46580     		NONE PC Operational Assistance 37,500
    UNCONDITIONAL GRANT Kosciusko County Community Foundation
    102 East Market Street
    Warsaw,IN46580     		NONE PC Good Samaritan Fund 137,500
    UNCONDITIONAL GRANT Kosciusko Home Care & Hospice
    1515 Provident Drive Ste 250
    Warsaw,IN46580     		NONE PC Operational Assistance 299,380
    UNCONDITIONAL GRANT Mad Anthony's Children's Hope House
    7922 West Jefferson Blvd
    Fort Wayne,IN46804     		NONE PC Operational Assistance 15,000
    UNCONDITIONAL GRANT North Webster UM Church
    7822 E Epworth Forest Rd
    North Webster,IN46555     		NONE PC Health Ed Program 7,000
    UNCONDITIONAL GRANT Questa Foundation for Education
    6502 Constitution Drive
    Fort Wayne,IN46804     		NONE PC Scholars Program 100,000
    UNCONDITIONAL GRANT Rose Home
    PO Box 571
    Syracuse,IN46567     		NONE PC Operational Assistance 10,000
    UNCONDITIONAL GRANT Ryan's Place
    PO Box 73
    Goshen,IN46527     		NONE PC Operational Assistance 5,000
    CONDITIONAL GRANT American Diabetes Association
    6415 Castleway West Dr Ste 114
    Indianapolis,IN46250     		NONE PC Scholarships for children attending diabetes camp 8,225
    CONDITIONAL GRANT American Legion Post 253
    756 S SR 13
    North Webster,IN46555     		NONE PC Handicap Accessible Van 29,889
    CONDITIONAL GRANT Baker Youth Club
    1401 E Smith St
    Warsaw,IN46580     		NONE PC Facility Support 20,000
    CONDITIONAL GRANT Bowen Center
    850 North Harrison St
    Warsaw,IN46580     		NONE PC Enchanted Hills Food Pantry 81,900
    CONDITIONAL GRANT Cardinal Services
    504 North Bay Dr
    Warsaw,IN46580     		NONE PC Handicap Accessible Van 15,000
    CONDITIONAL GRANT City of Warsaw
    102 S Buffalo St
    Warsaw,IN46580     		NONE PC Market St Pathway Development 375,000
    CONDITIONAL GRANT City of Warsaw
    102 S Buffalo St
    Warsaw,IN46580     		NONE PC Rescue Dive Boat and Cardiac Monitors 67,793
    CONDITIONAL GRANT Crosswinds
    4150 Illinois Rd
    Fort Wayne,IN46804     		NONE PC In-home Counseling services 8,945
    CONDITIONAL GRANT Fellowship Missions
    PO Box 382
    Winona Lake,IN46590     		NONE PC Facility Renovations 21,700
    CONDITIONAL GRANT Grace College & Seminary
    200 Seminary Drive
    Winona Lake,IN46590     		NONE PC Funds for Kosciusko Lakes & Streams research study 107,348
    CONDITIONAL GRANT Grace Village
    337 Grace Village Dr
    Winona Lake,IN46590     		NONE PC Rehabilitation Equipment 13,340
    CONDITIONAL GRANT Heartline Pregnancy Center
    1515 Provident Dr Ste 180
    Warsaw,IN46580     		NONE PC B.A.B.E. Boutique, Clinical Supplies, Car Seats, STI Testing 39,592
    CONDITIONAL GRANT Joe's Kids
    3540 Commerce Dr
    Warsaw,IN46580     		NONE PC Operating Assistance and equipment 18,000
    CONDITIONAL GRANT Kosciusko County YMCA
    1305 Mariners Dr
    Warsaw,IN46582     		NONE PC New Facility Development 400,000
    CONDITIONAL GRANT Kosciusko County Council on Aging
    800 Park Ave
    Warsaw,IN46580     		NONE PC Transportation Van 12,300
    CONDITIONAL GRANT Kosciusko County Shelter for Abuse
    PO Box 12
    Warsaw,IN46581     		NONE PC New Facility Development 304,442
    CONDITIONAL GRANT Kosciusko County
    221 W Main St
    Warsaw,IN46580     		NONE PC Dive Equipment and Drug Court Support 21,044
    CONDITIONAL GRANT Kosciusko Health Services Pavilion
    1515 Provident Dr
    Warsaw,IN46580     		NONE PC Phone System and HVAC Repair 48,971
    CONDITIONAL GRANT Kosciusko Home Care & Hospice
    1515 Provident Drive Ste 250
    Warsaw,IN46580     		NONE PC Children's Oral Health, Medication and Dental, Medical Supplies 188,878
    CONDITIONAL GRANT Lake City BMX Club
    5105 N Dovewood Trail
    Warsaw,IN46582     		NONE PC Track Renovations 47,461
    CONDITIONAL GRANT Magical Meadows
    3386 E 525 North
    Warsaw,IN46582     		NONE PC Parking Lot Renovations 30,000
    CONDITIONAL GRANT Multi-Township EMS
    34 E Armstrong Rd
    Leesburg,IN46538     		NONE PC Ambulance Cot Replacements 227,500
    CONDITIONAL GRANT North Webster Community Center
    PO Box 379
    North Webster,IN46555     		NONE PC Roof Replacement 31,097
    CONDITIONAL GRANT North Webster Tippecanoe Township
    PO Box 292
    North Webster,IN46555     		NONE PC ATV Rescue Vehicle 13,787
    CONDITIONAL GRANT Northern Indiana Hispanic Health Coalition
    323 Stocker Court
    Elkhart,IN46516     		NONE PC Operational funding for bilingual advocate/health fairs 35,000
    CONDITIONAL GRANT REAL Services
    720 E Winona Ave
    Warsaw,IN46580     		NONE PC Health Ed Workshops 1,500
    CONDITIONAL GRANT Serenity House
    2438 CR 50
    Auburn,IN46706     		NONE PC New Rehab Facility 100,000
    CONDITIONAL GRANT Silver Lake Fire Dept
    PO Box 64
    Silver Lake,IN46982     		NONE PC Equipment for Helipad 4,278
    CONDITIONAL GRANT Syracuse Wawasee Park Foundation
    1013 North Long Dr
    Syracuse,IN46567     		NONE PC Trails Systems Development 50,000
    CONDITIONAL GRANT Teen Parents Succeeding
    604 S Poplar Dr
    Syracuse,IN46567     		NONE PC Playground Renovation 19,100
    CONDITIONAL GRANT Tippecanoe Valley School Corp
    8343 S SR 19
    Akron,IN46910     		NONE PC Fitness Equipment 14,775
    CONDITIONAL GRANT Town of Pierceton
    PO Box 496
    Pierceton,IN46562     		NONE PC Pathway Development 125,000
    CONDITIONAL GRANT Town of Winona Lake
    1310 Park Ave
    Winona Lake,IN46590     		NONE PC Pathway Development 8,875
    CONDITIONAL GRANT Triton School Corp
    300 Triton Dr
    Bourbon,IN46504     		NONE PC Fitness Equipment 40,138
    CONDITIONAL GRANT other grants under 1000
    PO Box 1810
    Warsaw,IN465811810     		NONE PC K21 Board of Directors Directed Donation 994
    2nd Mile Mission
    PO Box 733
    Winona Lake,IN46590     		NONE PC K21 Board of Directors Directed Donation 1,000
    American Diabetes Association
    6415 Castleway West Dr Ste 114
    Indianapolis,IN46250     		NONE PC K21 Board of Directors Directed Donation 2,000
    BPO Elks Lodge #802
    310 E Center St
    Warsaw,IN46580     		NONE PC Support for the Underprivaleged 1,100
    Baker Youth Club
    1401 E Smith St
    Warsaw,IN46580     		NONE PC K21 Board of Directors Directed Donation 1,000
    Beaman Home
    PO Box 12
    Warsaw,IN46581     		NONE PC K21 Board of Directors Directed Donation 2,000
    Church of the Brethren
    2475 E 100 North
    Warsaw,IN46582     		NONE PC K21 Board of Directors Directed Donation 1,000
    First UM Church of Warsaw
    179 S Indiana St
    Warsaw,IN46580     		NONE PC Community Closet Support 5,000
    Grace College & Seminary
    200 Seminary Drive
    Winona Lake,IN46590     		NONE PC K21 Board of Directors Directed Donation and Smoking Cessation 2,000
    NorthStar Medical Equipment
    1241 Ridge Creek Trail
    Ada,MI49301     		NONE PC Automatic External Defibrillators and supplies 4,075
    Tippecanoe Valley Community Schools
    8343 South State Road 19
    Akron,IN16910     		NONE PC K21 Board of Directors Directed Donation 1,000
    Wagon Wheel Theater
    PO Box 804
    Warsaw,IN46581     		NONE PC K21 Board of Directors Directed Donation 1,000
    Warsaw Little League
    PO Box 153
    Warsaw,IN46581     		NONE PC K21 Board of Directors Directed Donation 1,000
    Other grants under 1000
    PO box 1810
    Warsaw,IN465811810     		NONE PC K21 Board of Directors Directed Donation 5,500
    Total .................................bullet 3a 3,427,569
    bApproved for future payment
    Total .................................bullet 3b 0
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 12
    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 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....          
    3
    Interest on savings and temporary cash investments ...........     		    14 554,339  
    4 Dividends and interest from securities....     14 1,050,011  
    5 Net rental income or (loss) from real estate:
    aDebt-financed property......          
    bNot debt-financed property.....     16 38,942  
    6
    Net rental income or (loss) from personal property     		         
    7 Other investment income.....     14 2,265  
    8
    Gain or (loss) from sales of assets other than inventory ............     		    18 2,642,580  
    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 4,288,137 0
    13Total. Add line 12, columns (b), (d), and (e)..................
    134,288,137
    (See worksheet in line 13 instructions 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 foundation’s exempt purposes (other than by providing funds for such purposes). (See
    instructions.)
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 13
    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 501(c) of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political organizations?
    Yes
    No
    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
    Sign Here
    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) is based on all information of which preparer has any knowledge.
    Bullet Bullet
    May the IRS discuss this return
    with the preparer shown below
    (see instr.)?
    Signature of officer or trustee Date Title
    Paid Preparer Use Only Print/Type preparer's name Preparer's Signature Date PTIN
    Firm's name SmallBullet
    		 Firm's EIN SmallBullet
    Firm's address SmallBullet


    		 Phone no.
    Form 990-PF (2015)
    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.
    Arrow Bullet Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990.
    OMB No. 1545-0047
    2015
    Name of the organization
    Kosciusko 21st Century Foundation Inc
    aka K21 Health Foundation
    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 on line H of its
    Form 990-EZ or on its Form 990PF, Part I, line 2, 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) (2015)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2015) Page 2
    Name of organization
    Kosciusko 21st Century Foundation Inc
    aka K21 Health Foundation         		Employer identification number
    35-1187105
    Part I
    Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    1
     
     

    Donette Smock  
    5867 E Island Ave
     
    Syracuse, IN46567

    		$ 30,100


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    2
     
     

    American Legion Post 253  
    PO Box 131
     
    North Webster, IN46555

    		$ 6,400


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    3
     
     

    Kosciusko Community Hospital  
    2101 E Dubois Drive
     
    Warsaw, IN46580

    		$ 5,500


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    4
     
     

    Donald Gunden  
    64874 Orchard Drive
     
    Goshen, IN46526

    		$ 5,000


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    5
     
     

    Douglas Schrock  
    631 E Northshore Dr
     
    Syracuse, IN46567

    		$ 5,000


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     

       
     
     

    		$  


    (Complete Part II for noncash contributions.)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
    Page 3
    Name of organization
    Kosciusko 21st Century Foundation Inc
    aka K21 Health Foundation         		Employer identification number

    35-1187105
    Part II
    Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
    (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) (2015)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
    Page 4
    Name of organization
    Kosciusko 21st Century Foundation Inc
    aka K21 Health Foundation         		Employer identification number

    35-1187105
    Part III
    Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. 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 $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
    Use duplicate copies of Part III if additional space is needed.
    (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) (2015)

    Additional Data


    Software ID:  
    Software Version:  

    TY 2015 AccountingFeesSchedule
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    ACCOUNTING FEES 26,700 0 0 26,700

    TY 2015 GeneralExplanationAttachment
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Identifier Return Reference Explanation
    SUPPLEMENTARY INFORMATION Form 990-PF, Part XV, Line 2A through 2d LINE 2, NAME OF THE GRANT PROGRAM: K21 HEALTH AND WELLNESS COMMUNITY GRANTSLINE 2A AND 2B, FORM AND CONTENT OF APPLICATION: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. GRANT APPLICATIONS CAN BE DOWNLOADED OR PRINTED FROM THE ORGANIZATION'S WEBSITE AT WWW.K21FOUNDATION.ORG UNDER "APPLY FOR GRANTS". GRANT APPLICATIONS ARE ACCEPTED FOUR TIMES EACH YEAR. APPLICATIONS RECEIVED AFTER THESE DEADLINES WILL BE HELD UNTIL THE NEXT CYCLE. ORIGINAL APPLICATION AND SUPPORTING DOCUMENTATION SHOULD BE SUBMITTED. TYPEWRITTEN APPLICATIONS ARE PREFERRED, HOWEVER, LEGIBLE HANDWRITTEN APPLICATIONS IN BLUE/BLACK INK ARE ACCEPTABLE. FOR ASSISTANCE COMPLETING THE APPLICATION CONTACT: GRANT COORDINATOR, HOLLY SWOVERLAND, AT (574) 269-5188 OR HSWOVERLAND@K21FOUNDATION.ORG.LINE 2C, ANY SUBMISSION DEADLINES: SUBMISSION DEADLINES ARE FEB 1ST, MAY 1ST, AUG 1ST, AND NOV 1ST.LINE 2D, RESTRICTIONS AND LIMITATIONS ON AWARDS: GRANTEES MUST MEET THE FOLLOWING REQUIREMENTS:A)NON-PROFIT AGENCY WITH VERIFIED IRS TAX-EXEMPT STATUS, OR A GOVERNMENT AGENCY. B)BE IN GOOD STANDING WITH THE INDIANA SECRETARY OF STATE AS INDICATED IN A BUSINESS ENTITY REPORT. C)BYLAWS MUST REQUIRE TERM LIMITS FOR DIRECTORS AND A ROTATING BOARD IS STRONGLY ENCOURAGED.GRANT REQUESTS MUST MEET THE FOLLOWING REQUIREMENTS:A)PROJECT, PROGRAM, OR SERVICES MUST BENEFIT RESIDENTS OF KOSCIUSKO COUNTY. B)K21 GRANT PRIORITIES ARE FOR HEALTH NEEDS OR HEALTH IMPROVEMENT. ALTHOUGH THE FOUNDATION CONSIDERS ANY GRANT OPPORTUNITIES THAT CLEARLY ADDRESSES HEALTH AND WELLNESS ISSUES FOR OUR COMMUNITY, OUR PRIRORITES FOR FUNDING CONSIDERATION FOCUS ON THE FOLLOWING:1)NON-PROFIT ORGANIZATIONS PROVIDING DIRECT HEALTH SERVICES TO PEOPLE IN NEED. 2)FUNDING ORGANIZATIONS THAT ARE MAKING ADVANCES OR PROVIDING SERVICES IN PREVENTION IMPROVEMENTS TO MINIMIZE THE NEED FOR HEALTH SERVICES. 3)SUPPORTING THOSE WHO ARE DEVELOPING AND IMPLEMENTING SOLUTIONS TOWARD PROVIDING OPPORTUNITIES TO PURSUE HEALTHY LIFESTYLES AND DECISIONS. 4)A COMMITMENT TO REGULAR, CONSISTENT ASSESSMENT AND PARTICIPATION IN THE DISCOVERY OF EXISTING HEALTH NEEDS OF OUR COMMUNITY.
    SUPPLEMENTARY INFORMATION Form 990-PF, Part XV, Line 2A through 2d LINE 2, NAME OF THE GRANT PROGRAM: CANCER CARE FUNDLINE 2A AND 2B, FORM AND CONTENT OF APPLICATION:THE KOSCIUSKO COUNTY CANCER CARE FUND, ADMINISTERED BY K21 HEALTH FOUNDATION, WAS ESTABLISHED FOR THE PURPOSE OF PROVIDING FINANCIAL ASSISTANCE TO FINANCIALLY-ELIGIBLE RESIDENTS OF KOSCIUSKO COUNTY WHO ARE SUFFERING FROM CANCER. THE PURPOSE OF THE FUND IS TO RELIEVE SOME OF THE FINANCIAL STRAIN THAT OFTEN ACCOMPANIES THAT DREADED DIAGNOSIS. THE ASSISTANCE PROVIDED INCLUDES BUT IS NOT LIMITED TO ITEMS SUCH AS RENT OR MORTGAGE PAYMENTS, UTILITIES, INSURANCE, FOOD, CAR PAYMENTS, AND PRESCRIPTION MEDICATIONS.IN NEARLY ALL SITUATIONS, FINANCIAL ASSISTANCE IS PAID DIRECTLY TO A VENDOR ON BEHALF OF THE CLIENTS. IN 2013 THE CANCER CARE FUND PROVIDED FINANCIAL ASSISTANCE TO MORE THAN 100 KOSCIUSKO COUNTY CANCER PATIENTS AND THEIR FAMILIES. THE FUND DISBURSED NEARLY $100,000 FOR ITEMS SUCH AS RENT OR MORTGAGE PAYMENTS, UTILITIES, INSURANCE, FOOD, AND PRESCRIPTION MEDICATIONS, JUST TO NAME A FEW. THE FUNDS ARE PRIMARILY RAISED BY A GROUP OF DEDICATED INDIVIDUALS IN KOSCIUSKO COUNTY WHO VOLUNTEER HUNDREDS OF HOURS EACH YEAR TO PLAN A NUMBER OF FUNDRAISING EVENTS, SUCH AS THE GOLF OUTING, GALA AND AUCTION.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. FOR APPLICATION ASSISTANCE, PLEASE CONTACT LAURA COOPER AT (574) 372-3500 OR LAURA@THEBEAMANHOME.ORGLINE 2C, ANY SUBMISSION DEADLINES: NONELINE 2D, RESTRICTIONS AND LIMITATIONS ON AWARDS: TO QUALIFY FOR ASSISTANCE, A RECIPIENT MUST PROVIDE:1. DOCUMENTED RESIDENT OF KOSCIUSKO COUNTY.2. VERIFIED CANCER DIAGNOSIS WITHIN THE LAST THREE MONTHS. 3. DEMONSTRATE A FINANCIAL NEED.4. COMPLETE REQUIRED APPLICATION.

    TY 2015 InvestmentsCorpBondsSchedule
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Name of Bond End of Year Book Value End of Year Fair Market Value
    CORPORATE BONDS 9,035,604 8,866,867
    Foreign Bonds 365,967 355,037

    TY 2015 InvestmentsCorpStockSchedule
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Name of Stock End of Year Book Value End of Year Fair Market Value
    EQUITY SECURITIES 33,820,865 41,331,672

    TY 2015 InvestmentsGovtObligationsSch
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    US Government Securities - End of Year Book Value:

    5,922,534
    US Government Securities - End of Year Fair Market Value:

    5,883,666
    State & Local Government Securities - End of Year Book Value:


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


    0


    TY 2015 InvestmentsLandSchedule2
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Category/ Item Cost/Other Basis Accumulated Depreciation Book Value End of Year Fair Market Value
    LAND 23,895 0 23,895 23,895
    Land Improvements 291,412 4,857 286,555 286,555
    Leasehold Improvements 554,764 10,542 544,222 544,222
    Building 1,023,544 223,247 800,297 800,297

    TY 2015 InvestmentsOtherSchedule2
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Category/ Item Listed at Cost or FMV Book Value End of Year Fair Market Value
    REAL ESTATE INVESTMENT FUND FMV 2,139,142 2,780,646
    Hedge FUND FMV 3,244,401 3,430,415

    TY 2015 LandEtcSchedule2
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Category / Item Cost / Other Basis Accumulated Depreciation Book Value End of Year Fair Market Value
    OFFICE & COMPUTER EQUIPMENT 87,393 84,602 2,791 2,791
    Construction in Progress 1,600 0 1,600 1,600


    TY 2015 LegalFeesSchedule
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Legal Fees 480 0 0 480


    TY 2015 OtherAssetsSchedule
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Description Beginning of Year - Book Value End of Year - Book Value End of Year - Fair Market Value
    Notes Receivable Held for grant making 3,598,650 4,007,053 4,007,053
    RECEIVABLE - OTHER 154 8,268 8,268


    TY 2015 OtherDecreasesSchedule
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Description Amount
    Unrealized Gain on Investments 3,552,649


    TY 2015 OtherExpensesSchedule
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    KHSP Mortgage Interest Forgiveness 149,900 0 0 0
    Harvest Loan Forgiveness 8,589 0 0 0
    Fundraising Expenses 51,856 0 0 51,856
    INSURANCE 6,948 0 0 6,900
    MARKETING 36,173 0 0 36,173
    MISCELLANEOUS EXPENSE 31,771 0 0 33,046
    Provident Expenses 12,865 12,865 0 0
    Expired Grants 5,840 0 0 0


    TY 2015 OtherIncomeSchedule2
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Description Revenue And Expenses Per Books Net Investment Income Adjusted Net Income
    Other Income 2,265 2,265  


    TY 2015 OtherIncreasesSchedule
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Description Amount
    2015 Book Value and Market Value Change between years 3,444,065


    TY 2015 OtherLiabilitiesSchedule
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Description Beginning of Year - Book Value End of Year - Book Value
    Deferred Tax Liability 105,533 81,198


    TY 2015 OtherProfessionalFeesSchedule
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    INVESTMENT MGT FEES 211,444 211,444 0 0


    TY 2015 TaxesSchedule
    Name:
    Kosciusko 21st Century Foundation Inc
     
    aka K21 Health Foundation
    EIN:
    35-1187105
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    EXCISE TAXES 16,624 0 0 0