TY 2015 Form 990EZ

Part IIIStatement of Program Service Accomplishments (see the instructions for Part III) Check if the organization used Schedule O to respond to any question in this Part III . .	Expenses (Required for section 501(c)(3) and 501(c)(4) organizations; optional for others.)
What is the organization's primary exempt purpose? TO SERVE THOSE AFFECTED BY HEART DISEASE IN THE MICHIANA AREA BY PROVIDING DIRECT ASSISTANCE TO LOCAL SCHOOLS, CHURCHES, AND NON-PROFIT ORGANIZATIONS AND PUBLIC VENUES.
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title.
28 THIS YEAR WE WERE ABLE TO PURCHASE 67 AUTOMATIC ELECTRONIC DEFIBRILLATORS (AEDS) AND PLACE THEM INTO THE COMMUNITY. THESE ARE LIFE-SAVING PIECES OF EQUIPMENT. (Grants $ 63,780) If this amount includes foreign grants, check here ...	28a	63,780
29 (Grants $ ) If this amount includes foreign grants, check here ...	29a
30 (Grants $ ) If this amount includes foreign grants, check here ...	30a
31 Other program services (describe in Schedule O) ................ (Grants $ ) If this amount includes foreign grants, check here...	31a
32 Total program service expenses (add lines 28a through 31a)..........	32	63,780

(a) Name and title	(b) Average hours per week devoted to position	(c)Reportable compensation (Forms W-2/1099-MISC) (if not paid, enter -0-)
WALTER HALLORAN MD PRESIDENT	0.50	0
KAREN WELDY MANAGER	10.00	1,905
CAREY DRURY BOARD MEMBER	0.50	0
TERRI RICKEL BOARD MEMBER	0.50	0

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust.
right arrow

Attach to Form 990 or Form 990-EZ.
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Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization

HEARTREACH MICHIANA INC

Employer identification number

20-2527524

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions.

The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990 or 990-EZ))

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box in lines 11a through 11d that describes the type of supporting organization and complete lines 11e, 11f, and 11g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations ..............

Provide the following information about the supported organization(s).

(i)Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i)Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2015

Page 2

Part II

Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any unusual grants.) ....	77,368	79,418	92,172	78,736	10,645	338,339
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3	77,368	79,418	92,172	78,736	10,645	338,339
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..						47,609
6	Public support. Subtract line 5 from line 4.						290,730

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(f) Total
7	Amounts from line 4..	77,368	79,418	92,172	78,736	10,645	338,339
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.)..
11	Total support. Add lines 7 through 10.						338,339

Gross receipts from related activities, etc. (see instructions) ..................

-60,361

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2015 (line 6, column (f) divided by line 11, column (f)) .........

85.930 %

Public support percentage for 2014 Schedule A, Part II, line 14 ...............

85.620 %

16a

33 1/3% support test—2015. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2014. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2015. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the facts-and-circumstances test, check this box and stop here. Explain
in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2014. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2015

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3	Gross receipts from activities that are not an unrelated trade or business under section 513...
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge..
6	Total. Add lines 1 through 5.
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public support. (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2015 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2014 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2015 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2014 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2015. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ....... right arrow

33 1/3% support tests—2014. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions .... right arrow

Schedule A (Form 990 or 990-EZ) 2015

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 11 of Part I. If you checked 11a of Part I, complete Sections A and B. If you checked 11b of Part I, complete Sections A and C. If you checked 11c of Part I, complete Sections A, D, and E. If you checked 11d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 11a or 11b in Part I, answer (b) and (c) below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Schedule A (Form 990 or 990-EZ) 2015

Page 5

Part IV

Supporting Organizations (continued)

Yes

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?

11a

A family member of a person described in (a) above?

11b

A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer (a) and (b) below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer (a) and (b) below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.

Schedule A (Form 990 or 990-EZ) 2015

Page 6

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970. See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	Section A - Adjusted Net Income		(A) Prior Year	(B) Current Year (optional)
1	Net short-term capital gain	1
2	Recoveries of prior-year distributions	2
3	Other gross income (see instructions)	3
4	Add lines 1 through 3	4
5	Depreciation and depletion	5
6	Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions)	6
7	Other expenses (see instructions)	7
8	Adjusted Net Income (subtract lines 5, 6 and 7 from line 4)	8

	Section B - Minimum Asset Amount		(A) Prior Year	(B) Current Year (optional)
1	Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year):	1
a	Average monthly value of securities	1a
b	Average monthly cash balances	1b
c	Fair market value of other non-exempt-use assets	1c
d	Total (add lines 1a, 1b, and 1c)	1d
e	Discount claimed for blockage or other factors (explain in detail in Part VI):
2	Acquisition indebtedness applicable to non-exempt use assets	2
3	Subtract line 2 from line 1d	3
4	Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions).	4
5	Net value of non-exempt-use assets (subtract line 4 from line 3)	5
6	Multiply line 5 by .035	6
7	Recoveries of prior-year distributions	7
8	Minimum Asset Amount (add line 7 to line 6)	8

	Section C - Distributable Amount		Current Year
1	Adjusted net income for prior year (from Section A, line 8, Column A)	1
2	Enter 85% of line 1	2
3	Minimum asset amount for prior year (from Section B, line 8, Column A)	3
4	Enter greater of line 2 or line 3	4
5	Income tax imposed in prior year	5
6	Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions)	6

Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990 or 990-EZ) 2015

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations (continued)

Section D - Distributions		Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity
3 Administrative expenses paid to accomplish exempt purposes of supported organizations
4 Amounts paid to acquire exempt-use assets
5 Qualified set-aside amounts (prior IRS approval required)
6 Other distributions (describe in Part VI). See instructions
7Total annual distributions. Add lines 1 through 6.
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions
9 Distributable amount for 2015 from Section C, line 6
10 Line 8 amount divided by Line 9 amount

Section E - Distribution Allocations (see instructions)		(i) Excess Distributions	(ii) Underdistributions Pre-2015	(iii) Distributable Amount for 2015
1 Distributable amount for 2015 from Section C, line 6
2 Underdistributions, if any, for years prior to 2015 (reasonable cause required--see instructions)
3 Excess distributions carryover, if any, to 2015:
a
b
c
d From 2013.......
e From 2014.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2015 distributable amount
i Carryover from 2010 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2015 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2015 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2015, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions)
6 Remaining underdistributions for 2015. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions)
7 Excess distributions carryover to 2016. Add lines 3j and 4c.
8 Breakdown of line 7:
a
b
c Excess from 2013.......
d From 2014.......
e From 2015.......

Schedule A (Form 990 or 990-EZ) (2015)

Schedule A (Form 990 or 990-EZ) 2015

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

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

HEARTREACH MICHIANA INC

Employer identification number

20-2527524

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

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

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year ......... 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 HEARTREACH MICHIANA INC

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
RESTRICTED	,	$ RESTRICTED	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (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 HEARTREACH MICHIANA INC		Employer identification number 20-2527524

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 HEARTREACH MICHIANA INC			Employer identification number 20-2527524
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.) $ Use duplicate copies of Part III if additional space is needed.

(a)
No.from Part I

(b) Purpose 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

(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

(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

(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:

- TIN:

SCHEDULE N
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Liquidation, Termination, Dissolution, or Significant Disposition of Assets

Complete if the organization answered "Yes" on Form 990, Part IV, lines 31 or 32; or Form 990-EZ, line 36.

Attach certified copies of any articles of dissolution, resolutions, or plans.
bullet

Attach to Form 990 or 990-EZ.
bullet

Information about Schedule N (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization
HEARTREACH MICHIANA INC

Employer identification number
20-2527524

Part I

Liquidation, Termination, or Dissolution. Complete this part if the organization answered "Yes" on Form 990, Part IV, line 31, or Form 990-EZ, line 36.
Part I can be duplicated if additional space is needed.

1(a) Description of asset(s) distributed or transaction expenses paid	(b) Date of distribution	(c) Fair market value of asset(s) distributed or amount of transaction expenses	(d) Method of determining FMV for asset(s) distributed or transaction expenses	(e) EIN of recipient	(f) Name and address of recipient	(g) IRC section of recipient(s) (if tax-exempt) or type of entity

REMAINING CASH IN CHECKING ACCOUNT DONATED TO A 501 (C)(3) CHARITY

12-31-2016

178

CASH

35-0933555

BASHOR CHILDREN'S HOME

1011 N MAIN ST
GOSHEN,IN46526

501 (C)(3)

Yes

Did or will any officer, director, trustee, or key employee of the organization:

Become a director or trustee of a successor or transferee organization? .........................

Become an employee of, or independent contractor for, a successor or transferee organization? .....................

Become a direct or indirect owner of a successor or transferee organization? .....................

Receive, or become entitled to, compensation or other similar payments as a result of the organization's liquidation, termination, or dissolution? ........

If the organization answered "Yes" to any of the questions on lines 2a through 2d, provide the name of the person involved and explain in Part III. bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or Form 990-EZ.

Cat. No. 50087Z

Schedule N (Form 990 or 990-EZ) (2015)

Page 2

Part I

Liquidation, Termination, or Dissolution (continued)

Note. If the organization distributed all of its assets during the tax year, then Form 990, Part X, column (B), line 16 (Total assets), and line 26 (Total liabilities), should equal -0-.

Yes

Did the organization distribute its assets in accordance with its governing instrument(s)? If "No," describe in Part III .............

Yes

Is the organization required to notify the attorney general or other appropriate state official of its intent to dissolve, liquidate, or terminate? ......

If "Yes," did the organization provide such notice? .....................

Did the organization discharge or pay all of its liabilities in accordance with state laws? .....................

Yes

Did the organization have any tax-exempt bonds outstanding during the year? .....................

If "Yes" on line 6a, did the organization discharge or defease all of its tax-exempt bond liabilities during the tax year in accordance with the Internal Revenue Code and state laws?

If "Yes" on line 6b, describe in Part III how the organization defeased or otherwise settled these liabilities. If "No" on line 6b, explain in Part III.

Part II

Sale, Exchange, Disposition, or Other Transfer of More Than 25% of the Organization's Assets. Complete this part if the organization answered "Yes" on Form 990, Part IV, line 32, or Form 990-EZ, line 36. Part II can be duplicated if additional space is needed.

1(a) Description of asset(s) distributed or transaction expenses paid	(b) Date of distribution	(c) Fair market value of asset(s) distributed or amount of transaction expenses	(d) Method of determining FMV for asset(s) distributed or transaction expenses	(e) EIN of recipient	(f) Name and address of recipient	(g) IRC section of recipient(s) (if tax-exempt) or type of entity

Yes

Did or will any officer, director, trustee, or key employee of the organization:

Become a director or trustee of a successor or transferee organization? .....................

Become an employee of, or independent contractor for, a successor or transferee organization? .....................

Become a direct or indirect owner of a successor or transferee organization? .....................

Receive, or become entitled to, compensation or other similar payments as a result of the organization’s significant disposition of assets? .....................

If the organization answered "Yes" to any of the questions on lines 2a through 2d, provide the name of the person involved and explain in Part III. bullet

Schedule N(Form 990 or 990-EZ) (2015)

Schedule N (Form 990 or 990-EZ) (2015)

Page 3

Part III

Supplemental Information. Provide the information required by Part I, lines 2e and 6c, and Part II, line 2e. Also complete this part to provide any additional information.

Return Reference	Explanation
SCHEDULE N PART III	ENTITY WAS DISSOLVED AS OF SEPTEMBER 30, 2016. ALL REMAINING ASSETS WERE DISTRIBUTED OUT AND BANK ACCOUNT CLOSED. ALL OF THE AUTOMATIC ELECTRONIC DEFIBRILLATORS (AEDS)WERE DONATED TO COMMUNITY ORGANIZATIONS (SEE 990 EZ PART I, LINE 10).THE ONLY OTHER REMAINING ASSET WAS THE ENDING CASH BALANCE OF $178.00 IN THE CHECKING ACCOUNT. THIS CASH WAS ALSO DISTRIBUTED OUT TO A 501(C)(3) ORGANIZATION(SEE SCHEDULE N PART I).

Return Reference

Explanation

SCHEDULE N PART III

ENTITY WAS DISSOLVED AS OF SEPTEMBER 30, 2016. ALL REMAINING ASSETS WERE DISTRIBUTED OUT AND BANK ACCOUNT CLOSED. ALL OF THE AUTOMATIC ELECTRONIC DEFIBRILLATORS (AEDS)WERE DONATED TO COMMUNITY ORGANIZATIONS (SEE 990 EZ PART I, LINE 10).THE ONLY OTHER REMAINING ASSET WAS THE ENDING CASH BALANCE OF $178.00 IN THE CHECKING ACCOUNT. THIS CASH WAS ALSO DISTRIBUTED OUT TO A 501(C)(3) ORGANIZATION(SEE SCHEDULE N PART I).

Schedule N (Form 990 or 990-EZ) (2015)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization

HEARTREACH MICHIANA INC

Employer identification number

20-2527524

Return Reference	Explanation
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: CITY OF ELKHART. GRANTEE ADDRESS: 201 S. SECOND ST. ELKHART, IN 46514. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 2. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 1,904. AMOUNT GIVEN: 1,904.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: CITY OF NAPPANEE. GRANTEE ADDRESS: 300 W. LINCOLN ST. NAPPANEE, IN 46550. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: CLAY FIRE DEPARTMENT. GRANTEE ADDRESS: 18355 AUTEN RD. SOUTH BEND, IN 46637. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 5. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 4,760. AMOUNT GIVEN: 4,760.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: CLAY UNITED METHODIST. GRANTEE ADDRESS: 52866 IRONWOOD DR. SOUTH BEND, IN 46635. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 2. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 1,904. AMOUNT GIVEN: 1,904.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: DEER RUN CHURCH/SCHOOL. GRANTEE ADDRESS: 2730 S. IRONWOOD DR. SOUTH BEND, IN 46614. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: DEAMICIS CLUB. GRANTEE ADDRESS: 302 W. 11TH ST. MISHAWAKA, IN 46544. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: EDWARDSBURG POLICE DEPT.. GRANTEE ADDRESS: P.O. BOX 650 EDWARDSBURG, MI 49112. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: ELKHART COUNTY FAIRGROUNDS. GRANTEE ADDRESS: 17746 CO. RD. 34 GOSHEN, IN 46528. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: ELKHART CO. HUMANE SOCIETY. GRANTEE ADDRESS: 54687 CO. RD. 19 BRISTOL, IN 46507. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: FIRST ASSEMBLY OF GOD. GRANTEE ADDRESS: 3084 NILES RD. ST. JOSEPH, MI 49085. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: FIRST BAPTIST CHURCH OF ELKHART. GRANTEE ADDRESS: 53953 CR 17 BRISTOL, IN 46507. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: FORAKER FIRE DEPARTMENT. GRANTEE ADDRESS: 69488 CR 117 NEW PARIS, IN 46553. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 2. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 1,904. AMOUNT GIVEN: 1,904.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: KNIGHTS OF COLUMBUS. GRANTEE ADDRESS: 112 E. LEXINGTON AVE. ELKHART, IN 46516. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: LITTLE FLOWER CATHOLIC CHURCH. GRANTEE ADDRESS: 54191 IRONWOOD RD. SOUTH BEND, IN 46635. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: MADISON TWP. VOL. FIRE DEPT.. GRANTEE ADDRESS: 66341 ST. RD. 331 WYATT, IN 46595. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: MARSHALL COUNTY POLICE DEPT.. GRANTEE ADDRESS: 1400 PIONEER DR. PLYMOUTH, IN 46563. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 5. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 4,760. AMOUNT GIVEN: 4,760.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: MENNONITE CHURCH USA. GRANTEE ADDRESS: 3145 BENHAM AVE. ELKHART, IN 46517. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: MISHAWAKA CITY SCHOOLS. GRANTEE ADDRESS: 1402 S. MAIN ST. MISHAWAKA, IN 46544. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 8. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 7,615. AMOUNT GIVEN: 7,615.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: NAPPANEE EMS. GRANTEE ADDRESS: 301 W. LINCOLN ST. NAPPANEE, IN 46550. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: NAPPANEE MISSIONARY CHURCH. GRANTEE ADDRESS: 70417 ST. RD. 19 NAPPANEE, IN 46550. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: NORTH LIBERTY POLICE DEPT.. GRANTEE ADDRESS: 116 N. MAIN ST. NORTH LIBERTY, IN 46554. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 3. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 2,856. AMOUNT GIVEN: 2,856.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: N.W. UNITED METHODIST CHURCH. GRANTEE ADDRESS: 21855 BRICK RD. SOUTH BEND, IN 46619. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: OUR LADY OF THE LAKE CATHOLIC CHURCH. GRANTEE ADDRESS: 24832 US 12 EDWARDSBURG, MI 49112. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: SILVERWOOD MENNONITE CHURCH. GRANTEE ADDRESS: 1712 W. CLINTON GOSHEN, IN 46526. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: SINAI SYNAGOGUE. GRANTEE ADDRESS: 1102 E. LASALLE ST. SOUTH BEND, IN 46617. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: ST. ADALBERT'S CHURCH. GRANTEE ADDRESS: 2505 GRACE ST. SOUTH BEND, IN 46619. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: ST. ADALBERT'S SCHOOL. GRANTEE ADDRESS: 519 S. OLIVE ST. SOUTH BEND, IN 46619. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: ST. ANDREW'S GREEK ORTHODOX CHURCH. GRANTEE ADDRESS: 52455 IRONWOOD RD. SOUTH BEND, IN 46635. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: ST. ANTHONY'S CATHOLIC SCHOOL. GRANTEE ADDRESS: 2310 E. JEFFERSON BLVD. SOUTH BEND, IN 46615. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: ST. JOE CO. POLICE DEPT.. GRANTEE ADDRESS: 401 W. SAMPLE ST. SOUTH BEND, IN 46601. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 6. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 5,709. AMOUNT GIVEN: 5,709.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: SUGAR GROVE CHURCH. GRANTEE ADDRESS: 58512 OLD CR 17 GOSHEN, IN 46528. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: TIPPICANOE TWP. VOL. FIRE DEPT.. GRANTEE ADDRESS: P.O. BOX 117 TIPPECANOE, IN 46570. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: VINEYARD COMMUNITY CHURCH. GRANTEE ADDRESS: 7566 E. 1000 N. SYRACUSE, IN 46567. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: BASHOR CHILDREN'S HOME. GRANTEE ADDRESS: 1011 N. MAIN ST GOSHEN, IN 46526. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 2. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 1,904. AMOUNT GIVEN: 1,904.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: BEAR LAKE CAMP. GRANTEE ADDRESS: 18053 16TH ST ALBION, IN 46701. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: BENTON TWP. FIRE DEPT.. GRANTEE ADDRESS: 68073 U.S. 33 GOSHEN, IN 46526. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 2. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 1,904. AMOUNT GIVEN: 1,904.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: BURR OAK VOLUNTEER FIRE DEPT.. GRANTEE ADDRESS: 208 W. FRONT STREET BURR OAK, MI 49030. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 3. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 2,856. AMOUNT GIVEN: 2,856.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: BURR OAK POLICE DEPT.. GRANTEE ADDRESS: 225 S. THIRD STREET BURR OAK, MI 49030. PROPERTY DESCRIPTION: DEFIBRILLATOR (AEDS) 1. METHOD USED TO DETERMINE BOOK VALUE: PURCHASE PRICE. METHOD USED TO DETERMINE FMV: PURCHASE PRICE. BOOK VALUE OF PROPERTY: 952. AMOUNT GIVEN: 952.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATION. GRANTEE NAME: BASHOR CHILDREN'S HOME. GRANTEE ADDRESS: 1011 N. MAIN ST GOSHEN, IN 46526. PROPERTY DESCRIPTION: CASH . BOOK VALUE OF PROPERTY: 178. AMOUNT GIVEN: 178. TOTAL INCLUDED ON FORM 990-EZ, LINE 10: 63,958.
FORM 990-EZ, PART I, LINE 16 - OTHER EXPENSES	DESCRIPTION: SUPPLIES. AMOUNT: 13. DESCRIPTION: MEETINGS. AMOUNT: 474. TOTAL TO FORM 990-EZ, LINE 16: 487.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

1	Contributions, gifts, grants, and similar amounts received ....................	1	10,645
2	Program service revenue including government fees and contracts ...............	2
3	Membership dues and assessments ...........................	3
4	Investment income ...........................	4
5a	Gross amount from sale of assets other than inventory .....	5a
b	Less: cost or other basis and sales expenses .......	5b
c	Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) ......	5c
6	Gaming and fundraising events
a	Gross income from gaming (attach Schedule G if greater than $15,000)	6a
b	Gross income from fundraising events (not including $ of contributions from fundraising events reported on line 1) (attach Schedule G if the			sum of such gross income and contributions exceeds $15,000) ..	6b
c	Less: direct expenses from gaming and fundraising events ...	6c	693
d	Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract line 6c)	6d	-693
7a	Gross sales of inventory, less returns and allowances ......	7a
b	Less: cost of goods sold .............	7b
c	Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) .........	7c
8	Other revenue (describe in Schedule O) ..........	8
9	Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 ..............	9	9,952

(a) Name and business address of each independent contractor	(b) Type of service	(c) Compensation
NONE

Sign Here

	Signature of officer	Date

	Type or print name and title

10	Grants and similar amounts paid (list in Schedule O) ............	10	63,958
11	Benefits paid to or for members ................	11
12	Salaries, other compensation, and employee benefits ................	12	1,905
13	Professional fees and other payments to independent contractors ............	13
14	Occupancy, rent, utilities, and maintenance ...................	14	790
15	Printing, publications, postage, and shipping ..............	15	19
16	Other expenses (describe in Schedule O) ..............	16	487
17	Total expenses. Add lines 10 through 16 ..............	17	67,159

18	Excess or (deficit) for the year (Subtract line 17 from line 9) ............	18	-57,207
19	Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with
	end-of-year figure reported on prior year’s return) ............	19	57,207
20	Other changes in net assets or fund balances (explain in Schedule O) ..........	20	0
21	Net assets or fund balances at end of year. Combine lines 18 through 20 .......	21	0