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.
bulletGo to www.irs.gov/Form990PF for instructions and the latest information.
OMB No. 1545-0052
2018
Open to Public Inspection
For calendar year 2018, or tax year beginning 01-01-2018 , and ending 12-31-2018
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. Foreign organizations, check here............. bullet
2. Foreign organizations meeting the 85%
test, check here and attach computation ... 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$69,163,858J 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) 536,025
2 Check bullet.............
3 Interest on savings and temporary cash investments 450,331 450,331  
4 Dividends and interest from securities... 1,035,283 1,035,283  
5a Gross rents............ 230,898 230,169  
b Net rental income or (loss) 77,012
6a Net gain or (loss) from sale of assets not on line 10 1,960,397
b Gross sales price for all assets on line 6a 33,039,096
7 Capital gain net income (from Part IV, line 2)... 1,960,397
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 86 86 0
12 Total. Add lines 1 through 11........ 4,213,020 3,676,266 0
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 198,234 0 0 198,234
14 Other employee salaries and wages...... 76,248 0 0 72,248
15 Pension plans, employee benefits....... 26,536 0 0 26,536
16a Legal fees (attach schedule).........        
b Accounting fees (attach schedule)....... Click to see attachment 18,025 0 0 18,025
c Other professional fees (attach schedule).... Click to see attachment 227,334 227,334 0 0
17 Interest...............        
18 Taxes (attach schedule) (see instructions)... Click to see attachment 32,950 0 0 0
19 Depreciation (attach schedule) and depletion... 154,702 152,382 0
20 Occupancy.............. 45,947 0 0 45,947
21 Travel, conferences, and meetings....... 11,460 0 0 11,460
22 Printing and publications.......... 2,264 0 0 2,264
23 Other expenses (attach schedule)....... Click to see attachment 1,054,344 1,504 0 128,910
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 1,848,044 381,220 0 503,624
25 Contributions, gifts, grants paid....... 2,817,167 2,765,855
26 Total expenses and disbursements. Add lines 24 and 25 4,665,211 381,220 0 3,269,479
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements -452,191
b Net investment income (if negative, enter -0-) 3,295,046
c Adjusted net income (if negative, enter -0-)... 0
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X Form 990-PF (2018)
Form 990-PF (2018)
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......... 1,142,163 1,420,996 1,420,996
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.......... 6,420 9,374 9,374
10a Investments—U.S. and state government obligations (attach schedule) 4,442,800 Click to see attachment4,137,117 4,132,037
b Investments—corporate stock (attach schedule)....... 30,811,741 Click to see attachment30,759,796 38,826,650
c Investments—corporate bonds (attach schedule)....... 7,579,592 Click to see attachment8,008,032 7,861,734
11 Investments—land, buildings, and equipment: basis bullet2,328,270
Less: accumulated depreciation (attach schedule) bullet651,211 1,823,101 Click to see attachment1,677,059 1,677,059
12 Investments—mortgage loans.............      
13 Investments—other (attach schedule).......... 12,528,870 Click to see attachment12,783,633 13,944,945
14 Land, buildings, and equipment: basis bullet68,643
Less: accumulated depreciation (attach schedule) bullet68,030 3,388 Click to see attachment613 613
15 Other assets (describe bullet) Click to see attachment2,147,815 Click to see attachment1,290,450 Click to see attachment1,290,450
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 60,485,890 60,087,070 69,163,858
Liabilities 17 Accounts payable and accrued expenses..........   9,945
18 Grants payable................. 293,541 336,967
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 attachment159,729 Click to see attachment90,768
23 Total liabilities (add lines 17 through 22)......... 453,270 437,680
Net Assets or Fund Balances Foundations that follow SFAS 117, check here bullet
and complete lines 24 through 26 and lines 30 and 31.
24 Unrestricted.................. 59,288,022 58,730,371
25 Temporarily restricted............... 744,598 919,019
26 Permanently restricted...............    
Foundations that do not follow SFAS 117, check here 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)..... 60,032,620 59,649,390
31 Total liabilities and net assets/fund balances (see instructions). 60,485,890 60,087,070
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
60,032,620
2
Enter amount from Part I, line 27a .....................
2
-452,191
3
Other increases not included in line 2 (itemize) bulletClick to see attachment
3
6,965,103
4
Add lines 1, 2, and 3 ..........................
4
66,545,532
5
Decreases not included in line 2 (itemize) bulletClick to see attachment
5
6,896,142
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 30 .
6
59,649,390
Form 990-PF (2018)
Form 990-PF (2018)
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 33,039,096   31,078,699 1,960,397
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       1,960,397
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 1,960,397
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))
2017 3,993,406 70,162,009 0.056917
2016 3,694,327 64,963,804 0.056867
2015 4,209,526 66,164,115 0.063622
2014 3,838,345 67,153,038 0.057158
2013 3,352,218 62,610,514 0.053541
2
Total of line 1, column (d) .....................
2
0.288105
3
Average distribution ratio for the 5-year base period—divide the total on line 2 by 5.0, or by the number of years the foundation has been in existence if less than 5 years ......
3
0.057621
4
Enter the net value of noncharitable-use assets for 2018 from Part X, line 5......
4
72,334,601
5
Multiply line 4 by line 3......................
5
4,167,992
6
Enter 1% of net investment income (1% of Part I, line 27b)...........
6
32,950
7
Add lines 5 and 6........................
7
4,200,942
8
Enter qualifying distributions from Part XII, line 4,.............
8
4,208,676
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 (2018)
Form 990-PF (2018)
Page 4
Part VI
Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see instructions)
1a Exempt operating foundations described in section 4940(d)(2), check here Bullet and enter “N/A" on line 1. Bracket includes lines 1a and 1b
Date of ruling or determination letter:   (attach copy of letter if necessary–see instructions)
b Domestic foundations that meet the section 4940(e) requirements in Part V, check 1 32,950
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 32,950
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 32,950
6 Credits/Payments:
a 2018 estimated tax payments and 2017 overpayment credited to 2018 6a 27,005
b Exempt foreign organizations—tax withheld at source...... 6b
c Tax paid with application for extension of time to file (Form 8868)... 6c 0
d Backup withholding erroneously withheld ........... 6d 0
7 Total credits and payments. Add lines 6a through 6d.............. 7 27,005
8 Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached. Click to see attachment 8 238
9 Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......Bullet 9 6,183
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 2019 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 2018 or the taxable year beginning in 2018? See the 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. Click to see attachment...............................
    10
    Yes
     
    Form 990-PF (2018)
    Form 990-PF (2018)
    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 —check here .........bullet
    and enter the amount of tax-exempt interest received or accrued during the year ........bullet
    15
     
    16 At any time during calendar year 2018, 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 the instructions for exceptions and filing requirements for FinCEN Form 114. 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
     
    No
    ........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 2018?.............
    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 2018, did the foundation have any undistributed income (lines 6d
    and 6e, Part XIII) for tax year(s) beginning before 2018?.............
    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 2018 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 2018.)..................
    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 2018?
    4b
     
    No
    Form 990-PF (2018)
    Form 990-PF (2018)
    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:
    Yes
    No
    (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
     
     
    8
    Is the foundation subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or
    excess parachute payment during the year? .................
    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     		192,646 5,438 150
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    SCOTT TUCKER CHAIRMAN
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    ANDREW GROSSNICKLE 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
    STEVE GRILL DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    JILL GROSS DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    RICK KERLIN DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    ANITA KISHAN DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    CHAD LARSH 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
    LISA O'NEILL 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
    DR JASMINE SCHLITT DIRECTOR
    1.00     		0 0 0
    2170 NORTH POINTE DRIVE
    WARSAW,IN46582
    BILL SMITH 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
    Form 990-PF (2018)
    Form 990-PF (2018)
    Page 7
    Part VIII
    Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
    and Contractors (continued)
    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
    MARQUETTE ASSOCIATES INVESTMENT CONSULTING 68,917
    180 N LASALLE SUITE 3500
    CHICAGO,IL60601
    Total number of others receiving over $50,000 for professional services.............bullet0
    Part IX-A
    Summary of Direct Charitable Activities
    List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc. Expenses
    1  
    2  
    3  
    4  
    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 PRINCIPAL AND INTEREST DUE FROM KOSCIUSKO HEALTH SERVICES PAVILION, INC., A SECTION 501(C(3) ORGANIZATION. 850,643
    2 FORGIVENESS OF CURRENT LOAN PRINCIPAL AND INTEREST DUE FROM HARVEST WITH A HEART, INC. A SECTION 501(C)(3) ORGANIZATION. 88,554
    All other program-related investments. See instructions.
    3  
    Total. Add lines 1 through 3.........................bullet939,197
    Form 990-PF (2018)
    Form 990-PF (2018)
    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
    72,891,593
    b
    Average of monthly cash balances.......................
    1b
    544,550
    c
    Fair market value of all other assets (see instructions)................
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    73,436,143
    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
    73,436,143
    4
    Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
    instructions) .............................
    4
    1,101,542
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    72,334,601
    6
    Minimum investment return. Enter 5% of line 5..................
    6
    3,616,730
    Part XI
    Distributable Amount (see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations and certain foreign organizations check here bullet and do not complete this part.)
    1
    Minimum investment return from Part X, line 6....................
    1
    3,616,730
    2a
    Tax on investment income for 2018 from Part VI, line 5......
    2a
    32,950
    b
    Income tax for 2018. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    32,950
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    3,583,780
    4
    Recoveries of amounts treated as qualifying distributions................
    4
    0
    5
    Add lines 3 and 4............................
    5
    3,583,780
    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
    3,583,780
    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
    3,269,479
    b
    Program-related investments—total from Part IX-B..................
    1b
    939,197
    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
    4,208,676
    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
    32,950
    6
    Adjusted qualifying distributions. Subtract line 5 from line 4..............
    6
    4,175,726
    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 (2018)
    Form 990-PF (2018)
    Page 9
    Part XIII
    Undistributed Income (see instructions)
    (a)
    Corpus     		(b)
    Years prior to 2017     		(c)
    2017     		(d)
    2018
    1 Distributable amount for 2018 from Part XI, line 7 3,583,780
    2 Undistributed income, if any, as of the end of 2018:
    a Enter amount for 2017 only....... 0
    b Total for prior years:20, 20, 20 0
    3 Excess distributions carryover, if any, to 2018:
    a From 2013......  
    b From 2014...... 87,852
    c From 2015...... 982,854
    d From 2016...... 515,855
    e From 2017...... 539,316
    fTotal of lines 3a through e........ 2,125,877
    4Qualifying distributions for 2018 from Part
    XII, line 4: bullet$ 4,208,676
    a Applied to 2017, 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 2018 distributable amount..... 3,583,780
    e Remaining amount distributed out of corpus 624,896
    5 Excess distributions carryover applied to 2018. 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 2,750,773
    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 2017. Subtract line
    4a from line 2a. Taxable amount—see
    instructions .............     		0
    f Undistributed income for 2018. Subtract
    lines 4d and 5 from line 1. This amount must
    be distributed in 2019 ..........     		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
    8 Excess distributions carryover from 2013 not
    applied on line 5 or line 7 (see instructions) ...     		0
    9Excess distributions carryover to 2019.
    Subtract lines 7 and 8 from line 6a ......     		2,750,773
    10 Analysis of line 9:
    a Excess from 2014.... 87,852
    b Excess from 2015.... 982,854
    c Excess from 2016.... 515,855
    d Excess from 2017.... 539,316
    e Excess from 2018.... 624,896
    Form 990-PF (2018)
    Form 990-PF (2018)
    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 2018, 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) 2018 (b) 2017 (c) 2016 (d) 2015
             
    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 foundation 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 (2018)
    Form 990-PF (2018)
    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 MEEKS
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,000
    CANCER CARE GRANT ALICE HENDERSON
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,335
    CANCER CARE GRANT ANITA SORIANO
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,000
    CANCER CARE GRANT ANNETTE COENEN
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,000
    CANCER CARE GRANT ANTHONY WILSON
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,000
    CANCER CARE GRANT CATHRYN TAYLOR
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,500
    CANCER CARE GRANT CAYLE WOODWARD
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,880
    CANCER CARE GRANT CHARLES SWIHART
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,500
    CANCER CARE GRANT CHRISTINE BROWN
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,335
    CANCER CARE GRANT CLINT CARDEN
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,700
    CANCER CARE GRANT CLOYD PRUITT
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,936
    CANCER CARE GRANT DANIEL FATTORUSSO
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,500
    CANCER CARE GRANT DAVID COBBS
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,480
    CANCER CARE GRANT DAVID COLLINS
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,932
    CANCER CARE GRANT DEBRA WALLACE
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 6,000
    CANCER CARE GRANT DONALD MASTERSON
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,571
    CANCER CARE GRANT DOROTHY SNYDER
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,650
    CANCER CARE GRANT EDWARD DEMPSEY
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,305
    CANCER CARE GRANT ERICA WEISSER
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,935
    CANCER CARE GRANT ERIN ALLISON
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,766
    CANCER CARE GRANT GEORGE HATCHER
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,500
    CANCER CARE GRANT GEORGINA MITCHELL
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,163
    CANCER CARE GRANT GERALD KONKLE
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,314
    CANCER CARE GRANT HEIDI PAUL
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,070
    CANCER CARE GRANT JAMES CLEMANS
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,341
    CANCER CARE GRANT JENNIFER MILLER
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,504
    CANCER CARE GRANT JIMMY HARTMAN
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,335
    CANCER CARE GRANT KATIE WYNKOOP
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,574
    CANCER CARE GRANT KEVIN HAINES
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,000
    CANCER CARE GRANT KRISTIN SUNDIN
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,428
    CANCER CARE GRANT LARRY SILVA
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,000
    CANCER CARE GRANT LIN JONES
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,628
    CANCER CARE GRANT LISA CASSEL
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,500
    CANCER CARE GRANT LISA OSBORN
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,536
    CANCER CARE GRANT LORENE MARVEL
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,917
    CANCER CARE GRANT MARK CLINGENPEEL
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,262
    CANCER CARE GRANT MARSHA MCGLENNEN
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,802
    CANCER CARE GRANT MERLIN SCHWARTZ
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,167
    CANCER CARE GRANT MICHELLE BAKER
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,000
    CANCER CARE GRANT NELIA DAVIS
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,600
    CANCER CARE GRANT NIKOLAI MARTINEZ
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,343
    CANCER CARE GRANT PATRICIA BOWSER
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,993
    CANCER CARE GRANT PENNY KRUECKEBERG
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,000
    CANCER CARE GRANT REBECCA MARSH
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,249
    CANCER CARE GRANT RICHARD MONROE
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,106
    CANCER CARE GRANT RICHARD SILVEUS
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,943
    CANCER CARE GRANT RON BRANDENBURG
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,200
    CANCER CARE GRANT RON HELMAN
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,021
    CANCER CARE GRANT RONNIE BALDRIDGE
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,500
    CANCER CARE GRANT ROSARIO NUNEZ
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 6,000
    CANCER CARE GRANT SANDY PALACIOS
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,887
    CANCER CARE GRANT SHANE SEWARD
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,815
    CANCER CARE GRANT SHELBA DEWELLS
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,000
    CANCER CARE GRANT STANLEY HUTCHISON
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,000
    CANCER CARE GRANT TERESA MOSS
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,700
    CANCER CARE GRANT TERRY KREFT
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,828
    CANCER CARE GRANT TINA TRUEX
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,059
    CANCER CARE GRANT VINCENT FLETCHER
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,000
    CANCER CARE GRANT WILLIAM WOOD
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,954
    CANCER CARE GRANT WILLIE FIELDS
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,109
    CANCER CARE GRANT OTHER GRANTS LESS
    PO BOX 1810
    WARSAW,IN465811810     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 24,080
    CONDITIONAL GRANT 2ND MILE ADVENTURES
    2562 WALTON BLVD 317
    WARSAW,IN46582     		NONE PC PROGRAM AND EQUIPMENT 8,766
    CONDITIONAL GRANT A BRIDGE TO HOPE
    499 E 450 SOUTH
    WARSAW,IN46580     		NONE PC OPERATIONAL ASSISTANCE 64,960
    CONDITIONAL GRANT AGAITAS
    1945 PHEASANT RIDGE DR
    WARSAW,IN46580     		NONE PC EQUIPMENT 7,582
    CONDITIONAL GRANT AMERICAN DIABETES ASSOCIATION
    6415 CASTLEWAY WEST DR STE 114
    INDIANAPOLIS,IN46250     		NONE PC SCHOLARSHIPS FOR CHILDREN ATTENDING DIABETES CAMP 5,100
    CONDITIONAL GRANT BAKER YOUTH CLUB
    1401 E SMITH ST
    WARSAW,IN46580     		NONE PC EQUIPMENT 48,551
    CONDITIONAL GRANT BOWEN CENTER
    2621 E JEFFERSON ST
    WARSAW,IN46580     		NONE PC ASSESSMENT, EQUIPMENT, OPERATIONAL 69,105
    CONDITIONAL GRANT GRACE COLLEGE & SEMINARY
    200 SEMINARY DRIVE
    WINONA LAKE,IN46590     		NONE PC RESEARCH AND FACILITY EXPANSION 717,087
    CONDITIONAL GRANT HEALTHY COMMUNITY COALITION
    8546 S 200 WEST
    CLAYPOOL,IN46510     		NONE PC TOBACCO USE REDUCTION AND PREVENTION PROGRAMS 33,592
    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 31,208
    CONDITIONAL GRANT HOUSING OPPORTUNITIES OF WARSAW
    109 W CATHERINE ST
    MILFORD,IN46542     		NONE PC HOME REPAIRS 10,614
    CONDITIONAL GRANT JOE'S KIDS
    902 PROVIDENT DR SUITE C
    WARSAW,IN46580     		NONE PC OPERATIONAL ASSISTANCE 41,221
    CONDITIONAL GRANT KCV CYCLING CLUB
    PO BOX 325
    WINONA LAKE,IN46590     		NONE PC MAINTENANCE EQUIPMENT 13,891
    CONDITIONAL GRANT KOSCIUSKO COUNTY COUNCIL ON AGING
    800 PARK AVE
    WARSAW,IN46580     		NONE PC TRANSPORTATION VAN 10,400
    CONDITIONAL GRANT KOSCIUSKO HOME CARE & HOSPICE
    1515 PROVIDENT DRIVE STE 250
    WARSAW,IN46580     		NONE PC CHILDREN'S ORAL HEALTH, MEDICATION AND DENTAL, MEDICAL SUPPLIES 315,076
    CONDITIONAL GRANT LAKELAND CHRISTIAN ACADEMY
    1095 S 250 E
    WINONA LAKE,IN46590     		NONE PC NURSE FACILITY AND EQUIPMENT 5,000
    CONDITIONAL GRANT MENTONE YOUTH LEAGUE
    PO BOX 233
    MENTONE,IN46539     		NONE PC FACILITY IMPROVEMENT 24,815
    CONDITIONAL GRANT NORTHERN INDIANA HISPANIC HEALTH COALITION
    323 STOCKER COURT
    ELKHART,IN46516     		NONE PC OPERATIONAL FUNDING FOR BILINGUAL ADVOCATE/HEALTH FAIRS 59,775
    CONDITIONAL GRANT QUESTA FOUNDATION
    6502 CONSTITUTION DR
    FORT WAYNE,IN46804     		NONE PC HEALTH SCHOLARS PROGRAM 100,000
    CONDITIONAL GRANT THE ROSE HOME
    PO BOX 571
    SYRACUSE,IN46567     		NONE PC HOME REPAIRS AND OPERATIONAL ASSISTANCE 11,954
    CONDITIONAL GRANT THE WATERSHED FOUNDATION
    PO BOX 55
    NORTH WEBSTER,IN46555     		NONE PC COMMUNITY OUTREACH AND EDUCATION 31,817
    CONDITIONAL GRANT TIPPECANOE VALLEY SCHOOL CORP
    8643 S STATE ROAD 19
    AKRON,IN46910     		NONE PC EQUIPMENT 133,907
    CONDITIONAL GRANT WARSAW LITTLE LEAGUE
    PO BOX 153
    WARSAW,IN46581     		NONE PC FACILITY IMPROVEMENT 4,215
    CONDITIONAL GRANT WAWASEE COMMUNITY SCHOOLS
    502 W BROOKLYN ST
    SYRACUSE,IN46567     		NONE PC EQUIPMENT 63,787
    CONDITIONAL GRANT YOUNG TIGER FOOTBALL
    PO BOX 1362
    WARSAW,IN46581     		NONE PC EQUIPMENT 6,939
    DIRECT GRANT 212 MEDIA STUDIOS
    929 E CENTER ST
    WARSAW,IN46580     		NONE PC NONPROFIT COMMUNICATIONS WORKSHOP 2,500
    DIRECT GRANT A BRIDGE TO HOPE
    301 N LAKE ST
    WARSAW,IN46580     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION 1,000
    DIRECT GRANT AGAITAS
    1945 PHEASANT RIDGE DR
    WARSAW,IN46580     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION 2,000
    DIRECT GRANT AMERICAN DIABETES ASSOCIATION
    6415 CASTLEWAY WEST DR STE 114
    INDIANAPOLIS,IN46250     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION 1,000
    DIRECT GRANT AMERICAN LUNG ASSOCIATION
    115 W WASHINGTON ST STE 1180
    INDIANAPOLIS,IN46204     		NONE PC SMOKING CESSATION TRAINING 1,050
    DIRECT GRANT BAKER YOUTH CLUB
    1401 E SMITH ST
    WARSAW,IN46580     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION, OPERATIONAL 21,000
    DIRECT GRANT BOWEN CENTER
    2621 E JEFFERSON ST
    WARSAW,IN46580     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION, OPERATIONAL 20,300
    DIRECT GRANT CARDINAL SERVICES
    504 N BAY DR
    WARSAW,IN46580     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION, OPERATIONAL 21,500
    DIRECT GRANT CITY COUNTY ATHLETIC COMPLEX
    3215 W OLD RD 30
    WARSAW,IN46580     		NONE PC OPERATIONAL ASSISTANCE 20,000
    DIRECT GRANT CITY OF WARSAW
    102 S BUFFALO ST
    WARSAW,IN46580     		NONE PC PARK REDEVELOPMENT PLAN 14,000
    DIRECT GRANT COMBINED COMMUNITY SERVICES
    3215 W OLD RD 30
    WARSAW,IN46580     		NONE PC OPERATIONAL ASSISTANCE 20,000
    DIRECT GRANT GRACE COLLEGE & SEMINARY
    200 SEMINARY DRIVE
    WINONA LAKE,IN46590     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION 2,000
    DIRECT GRANT HARVEST WITH A HEART
    201 S HIGBEE ST
    MILFORD,IN36542     		NONE PC OPERATIONAL ASSISTANCE 1,000
    DIRECT GRANT HEARTLINE PREGANCY CENTER
    1515 PROVIDENT DR SUITE 180
    WARSAW,IN46580     		NONE PC OPERATIONAL ASSISTANCE 20,000
    DIRECT GRANT JOE'S KIDS
    902 PROVIDENT DR SUITE C
    WARSAW,IN46580     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION 1,000
    DIRECT GRANT KOSCIUSKO COMMUNITY YMCA
    1305 MARINERS DR
    WARSAW,IN46582     		NONE PC OPERATIONAL ASSISTANCE 42,500
    DIRECT GRANT KOSCIUSKO COUNTY COUNCIL ON AGING
    800 PARK AVE
    WARSAW,IN46580     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION, OPERATIONAL 21,000
    DIRECT GRANT KOSCIUSKO COUNTY SHELTER FOR ABUSE
    PO BOX 12
    WARSAW,IN46581     		NONE PC OPERATIONAL ASSISTANCE 20,000
    DIRECT GRANT KOSCIUSKO HOME CARE & HOSPICE
    1515 PROVIDENT DRIVE STE 250
    WARSAW,IN46580     		NONE PC OPERATIONAL ASSISTANCE 20,000
    DIRECT GRANT MILESTONES EARLY EDUCATION CENTER
    PO BOX 316
    N WEBSTER,IN46555     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION 1,000
    DIRECT GRANT NORTHERN INDIANA HISPANIC HEALTH COALITION
    323 STOCKER COURT
    ELKHART,IN46516     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION 1,000
    DIRECT GRANT RILEY CHILDREN'S FOUNDATION
    30 SOUTH MERIDIAN ST
    INDIANAPOLIS,IN46204     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION 1,000
    DIRECT GRANT SOCIETY OF ST ANDREW
    7840 DITCH ROAD
    INDIANAPOLIS,IN46260     		NONE PC FOOD TRANSPORTATION FOR NEED-BASED PROGRAMS 3,500
    DIRECT GRANT WAGON WHEEL THEATRE INC
    2515 E CENTER ST
    WARSAW,IN46580     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION 1,500
    DIRECT GRANT WARSAW COMMUNITY SCHOOLS
    1 ADMINISTRATION DR
    WARSAW,IN46580     		NONE PC MENTAL HEALTH CONVOCATIONS 2,000
    DIRECT GRANTS OTHER GRANTS UNDER 1000
    PO BOX 1810
    WARSAW,IN465811810     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION 4,812
    UNCONDITIONAL GRANT A BRIDGE TO HOPE
    499 E 450 SOUTH
    WARSAW,IN46580     		NONE PC OPERATIONAL ASSISTANCE 25,000
    UNCONDITIONAL GRANT ALL THINGS NEW
    PO BOX 367
    WINONA LAKE,IN46590     		NONE PC OPERATIONAL ASSISTANCE 4,786
    UNCONDITIONAL GRANT BAKER YOUTH CLUB
    1401 E SMITH ST
    WARSAW,IN46580     		NONE PC SUMMER FITNESS PROGRAM 20,000
    UNCONDITIONAL GRANT BIG BROTHERS BIG SISTERS
    499 E 450 SOUTH
    WARSAW,IN46580     		NONE PC OPERATIONAL ASSISTANCE 5,000
    UNCONDITIONAL GRANT BRIGHTPOINT
    227 E WASHINGTON BLVD
    FORT WAYNE,IN46804     		NONE PC OPERATIONAL ASSISTANCE 17,500
    UNCONDITIONAL GRANT CANCER SERVICES OF NORTHEAST INDIANA
    6316 MUTUAL DRIVE
    FORT WAYNE,IN46825     		NONE PC DIRECT ASSISTANCE / CLIENT ADVOCACY 15,000
    UNCONDITIONAL GRANT CARDINAL SERVICES
    504 N BAY DR
    WARSAW,IN46580     		NONE PC COMMUNICATIONS IMPROVEMENT 10,200
    UNCONDITIONAL GRANT HEARTLINE PREGNANCY CENTER
    1515 PROVIDENT DRIVE
    WARSAW,IN46580     		NONE PC MOBILE UNIT OPERATIONS 10,000
    UNCONDITIONAL GRANT KOSCIUSKO COMMUNITY YMCA
    1305 MARINERS DR
    WARSAW,IN46582     		NONE PC OPERATIONAL ASSISTANCE 45,100
    UNCONDITIONAL GRANT KOSCIUSKO COUNTY COMMUNITY FOUNDATION
    102 EAST MARKET STREET
    WARSAW,IN46580     		NONE PC GOOD SAMARITAN FUND 156,250
    UNCONDITIONAL GRANT KOSCIUSKO HOME CARE & HOSPICE
    1515 PROVIDENT DRIVE STE 250
    WARSAW,IN46580     		NONE PC OPERATIONAL ASSISTANCE 163,742
    UNCONDITIONAL GRANT MAD ANTHONY'S CHILDREN'S HOPE HOUSE
    7922 WEST JEFFERSON BLVD
    FORT WAYNE,IN46804     		NONE PC OPERATIONAL ASSISTANCE 10,000
    UNCONDITIONAL GRANT MAGICAL MEADOWS
    3386 E 525 NORTH
    WARSAW,IN46582     		NONE PC COMMUNICATIONS IMPROVEMENT 10,000
    UNCONDITIONAL GRANT YOUNG TIGER FOOTBALL
    PO BOX 1362
    WARSAW,IN46581     		NONE PC COMMUNICATIONS IMPROVEMENT 7,500
    Total .................................bullet 3a 2,765,855
    bApproved for future payment
    Total .................................bullet 3b 0
    Form 990-PF (2018)
    Form 990-PF (2018)
    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 ...........     		    14 450,331  
    4 Dividends and interest from securities....     14 1,035,283  
    5 Net rental income or (loss) from real estate:
    aDebt-financed property......          
    bNot debt-financed property.....     16 77,012  
    6 Net rental income or (loss) from personal property          
    7 Other investment income.....     14 86  
    8 Gain or (loss) from sales of assets other than
    inventory ............     		    18 1,960,397  
    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 3,523,109 0
    13Total. Add line 12, columns (b), (d), and (e)..................
    13
    3,523,109
    (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 (2018)
    Form 990-PF (2018)
    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) (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) (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 (2018)
    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 Go to www.irs.gov/Form990 for the latest information.
    OMB No. 1545-0047
    2018
    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 isn't covered by the General Rule and/or the Special Rules doesn't 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 doesn't 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) (2018)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2018) 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
    DR AND MRS RICK SASSO
     
    10674 WINTERWOOD
     
    CARMEL, IN46032

    		$ 200,123


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    2
    LUTHERAN HEALTH FOUNDATION
     
    3024 FAIRFIELD AVE
     
    FORT WAYNE, IN46807

    		$ 5,500


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    3
    LEIGHTON WELLS
     
    7991 E CHEROKEE RD
     
    SYRACUSE, IN46567

    		$ 5,500


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    4
    DOUGLAS SCHROCK
     
    631 E NORTHSHORE DR
     
    SYRACUSE, IN46567

    		$ 10,000


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    5
    DONETTE SMOCK
     
    5867 E ISLAND AVE
     
    SYRACUSE, IN46567

    		$ 15,295


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    6
    BRIAN HULL
     
    7796 E VAWTER PARK RD
     
    SYRACUSE, IN46567

    		$ 5,250


    (Complete Part II for noncash contributions.)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2018)
    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
    7
    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
    8
    BERTSCH FAMILY CHARITABLE FOUNDATION
     
    PO BOX 1494
     
    WARSAW, IN46581

    		$ 7,500


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    9
    W MERWIN FORBES
     
    1433 CAMELOT DR
     
    WINONA LAKE, IN46590

    		$ 5,000


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    10
    MULTI-TOWNSHIP EMS
     
    34 E ARMSTRONG RD
     
    LEESBURG, IN46538

    		$ 123,732


    (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.)
    (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) (2018)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2018)
    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
    1
    		 MARKETABLE SECURITIES $ 200,123 2018-12-31
    (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) (2018)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2018)
    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) (2018)

    Additional Data


    Software ID:  
    Software Version:  

    TY 2018 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 18,025 0 0 18,025

    TY 2018 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 LIVING. 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 ACCESSED THROUGH AN ONLINE PROCESS 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. 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 PRIORITIES 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 ALL SITUATIONS, FINANCIAL ASSISTANCE IS PAID DIRECTLY TO A VENDOR ON BEHALF OF THE CLIENTS. IN 2017 THE CANCER CARE FUND PROVIDED FINANCIAL ASSISTANCE TO OVER 100 KOSCIUSKO COUNTY CANCER PATIENTS AND THEIR FAMILIES. THE FUND DISBURSED APPROXIMATELY $185,000 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 DEAL-DECKER AT (574) 372-3500 OR LAURA@KOSHELPCENTER.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 2018 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 7,491,563 7,354,372
    FOREIGN BONDS 516,469 507,362

    TY 2018 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 30,759,796 38,826,650

    TY 2018 InvestmentsGovtObligationsSch
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
     
    AKA K21 HEALTH FOUNDATION
    EIN:
    35-1187105
    US Government Securities - End of Year Book Value:

    4,137,117
    US Government Securities - End of Year Fair Market Value:

    4,132,037
    State & Local Government Securities - End of Year Book Value:


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


    0


    TY 2018 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 311,605 104,601 207,004 207,004
    LEASEHOLD IMPROVEMENTS 969,226 367,489 601,737 601,737
    BUILDING 1,023,544 179,121 844,423 844,423

    TY 2018 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 2,328,475 3,191,856
    HEDGE FUND FMV 4,037,964 3,465,756
    GLOBAL MANAGED VOLATILITY FMV 3,071,287 3,883,913
    US EQUITY INDEX PUTWRITE FUND LLC FMV 3,345,907 3,403,420

    TY 2018 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 68,643 68,030 613 613


    TY 2018 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 2,139,032 1,288,792 1,288,792
    RECEIVABLE - OTHER 929 1,658 1,658
    EXCISE TAX ASSET - OVERPAYMENT 7,854 0 0


    TY 2018 OtherDecreasesSchedule
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
     
    AKA K21 HEALTH FOUNDATION
    EIN:
    35-1187105
    Description Amount
    UNREALIZED GAIN ON INVESTMENTS 6,896,142


    TY 2018 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 850,643 0 0 0
    HARVEST LOAN FORGIVENESS 88,554 0 0 0
    FUNDRAISING EXPENSES 40,044 0 0 40,044
    INSURANCE 7,272 0 0 10,701
    MARKETING 40,688 0 0 40,688
    MISCELLANEOUS EXPENSE 39,456 1,504 0 37,477
    EXPIRED GRANTS -12,313 0 0 0


    TY 2018 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 86 86  


    TY 2018 OtherIncreasesSchedule
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
     
    AKA K21 HEALTH FOUNDATION
    EIN:
    35-1187105
    Description Amount
    2018 BOOK VALUE AND MARKET VALUE CHANGE BETWEEN YEARS 6,896,142
    CHANGE IN DEFERRED TAX ASSETS 68,961


    TY 2018 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 159,729 90,768


    TY 2018 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 227,334 227,334 0 0


    TY 2018 SubstantialContributorsSch
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
     
    AKA K21 HEALTH FOUNDATION
    EIN:
    35-1187105
    Name Address
    DR AND MRS RICK SASSO 10674 WINTERWOOD
    CARMEL,IN46032
    LUTHERAN HEALTH FOUNDATION 3024 FAIRFIELD AVENUE
    FORT WAYNE,IN46807
    MULTI-TOWNSHIP EMS 34 E ARMSTRONG RD
    LEESBURG,IN46538


    TY 2018 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 32,950 0 0 0