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
2020
Open to Public Inspection
For calendar year 2020, or tax year beginning 01-01-2020 , and ending 12-31-2020
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)1101 PARK AVE
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
WINONA LAKE, IN46590
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$83,032,013J 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) 333,267
2 Check bullet.............
3 Interest on savings and temporary cash investments 390,905 390,905  
4 Dividends and interest from securities... 977,125 977,125  
5a Gross rents............ 252,710 252,710  
b Net rental income or (loss) 64,537
6a Net gain or (loss) from sale of assets not on line 10 2,877,980
b Gross sales price for all assets on line 6a 50,118,310
7 Capital gain net income (from Part IV, line 2)... 2,877,980
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 3,081 3,081 0
12 Total. Add lines 1 through 11........ 4,835,068 4,501,801 0
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 221,057 0 0 221,057
14 Other employee salaries and wages...... 102,177 0 0 99,931
15 Pension plans, employee benefits....... 25,956 0 0 25,956
16a Legal fees (attach schedule).........        
b Accounting fees (attach schedule)....... Click to see attachment 19,150 0 0 19,150
c Other professional fees (attach schedule).... Click to see attachment 229,069 229,069 0 0
17 Interest...............        
18 Taxes (attach schedule) (see instructions)... Click to see attachment 111,454 47 0 0
19 Depreciation (attach schedule) and depletion... 180,691 180,691 0
20 Occupancy.............. 31,980 0 0 31,980
21 Travel, conferences, and meetings....... 2,961 0 0 2,961
22 Printing and publications.......... 4,732 0 0 4,732
23 Other expenses (attach schedule)....... Click to see attachment 136,904 7,482 0 99,118
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 1,066,131 417,289 0 504,885
25 Contributions, gifts, grants paid....... 2,667,830 2,681,075
26 Total expenses and disbursements. Add lines 24 and 25 3,733,961 417,289 0 3,185,960
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements 1,101,107
b Net investment income (if negative, enter -0-) 4,084,512
c Adjusted net income (if negative, enter -0-)... 0
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X Form 990-PF (2020)
Form 990-PF (2020)
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......... 1,460,596 657,305 657,305
3 Accounts receivable bullet  
Less: allowance for doubtful accounts bullet        
4 Pledges receivable bullet  
Less: allowance for doubtful accounts bullet        
5 Grants receivable.................      
6 Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see instructions).....      
7 Other notes and loans receivable (attach schedule) bullet  
Less: allowance for doubtful accounts bullet        
8 Inventories for sale or use..............      
9 Prepaid expenses and deferred charges.......... 7,430 10,109 10,109
10a Investments—U.S. and state government obligations (attach schedule) 5,028,571 Click to see attachment6,051,741 6,053,922
b Investments—corporate stock (attach schedule)....... 30,222,616 Click to see attachment31,076,371 49,951,449
c Investments—corporate bonds (attach schedule)....... 7,530,216 Click to see attachment6,800,646 7,101,934
11 Investments—land, buildings, and equipment: basis bullet3,226,514
Less: accumulated depreciation (attach schedule) bullet987,490 1,965,140 Click to see attachment2,239,024 2,239,024
12 Investments—mortgage loans.............      
13 Investments—other (attach schedule).......... 13,582,160 Click to see attachment13,996,621 16,114,687
14 Land, buildings, and equipment: basis bullet122,885
Less: accumulated depreciation (attach schedule) bullet8,566 0 Click to see attachment114,319 114,319
15 Other assets (describe bullet) Click to see attachment789,978 Click to see attachment789,264 Click to see attachment789,264
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 60,586,707 61,735,400 83,032,013
Liabilities 17 Accounts payable and accrued expenses.......... 8,681 14,881
18 Grants payable................. 293,442 280,196
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 attachment241,391 Click to see attachment296,023
23 Total liabilities (add lines 17 through 22)......... 543,514 591,100
Net Assets or Fund Balances Foundations that follow FASB ASC 958, check here bullet
and complete lines 24, 25, 29 and 30.
24 Net assets without donor restrictions........... 58,938,930 59,898,578
25 Net assets with donor restrictions............ 1,104,263 1,245,722
Foundations that do not follow FASB ASC 958, check here bullet
and complete lines 26 through 30.
26 Capital stock, trust principal, or current funds........    
27 Paid-in or capital surplus, or land, bldg., and equipment fund    
28 Retained earnings, accumulated income, endowment, or other funds    
29 Total net assets or fund balances (see instructions)..... 60,043,193 61,144,300
30 Total liabilities and net assets/fund balances (see instructions). 60,586,707 61,735,400
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 29 (must agree with end-of-year figure reported on prior year’s return) ...............
1
60,043,193
2
Enter amount from Part I, line 27a .....................
2
1,101,107
3
Other increases not included in line 2 (itemize) bullet
3
0
4
Add lines 1, 2, and 3 ..........................
4
61,144,300
5
Decreases not included in line 2 (itemize) bullet
5
0
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29 .
6
61,144,300
Form 990-PF (2020)
Form 990-PF (2020)
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 SALES OF SECURITIES      
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 50,118,310   47,240,330 2,877,980
b
c
d
e
Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69 (l)
Gains (Col. (h) gain minus
col. (k), but not less than -0-) or
Losses (from col.(h))
(i)
F.M.V. as of 12/31/69 		(j)
Adjusted basis
as of 12/31/69 		(k)
Excess of col. (i)
over col. (j), if any
a       2,877,980
b
c
d
e
2 Capital gain net income or (net capital loss) Bracket If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7		 Bracket 2 2,877,980
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
SECTION 4940(e) REPEALED ON DECEMBER 20, 2019 - DO NOT COMPLETE
1 Reserved
(a)
Reserved 		(b)
Reserved 		(c)
Reserved 		(d)
Reserved
2
Reserved...........................
2
3
Reserved...........................
3
4
Reserved...........................
4
5
Reserved...........................
5
6
Reserved...........................
6
7
Reserved...........................
7
8
Reserved,..........................
8
Form 990-PF (2020)
Form 990-PF (2020)
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 for line 1a
Date of ruling or determination letter:   (attach copy of letter if necessary–see instructions)
b Reserved................................ 1 56,775
c All other domestic foundations enter 1.39% 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 56,775
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 56,775
6 Credits/Payments:
a 2020 estimated tax payments and 2019 overpayment credited to 2020 6a 44,140
b Exempt foreign organizations—tax withheld at source...... 6b 0
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 44,140
8 Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached. Click to see attachment 8 260
9 Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......Bullet 9 12,895
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 2021 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 the instructions
for the 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 2020 or the taxable year beginning in 2020? 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. ...............................
    10
     
    No
    Form 990-PF (2020)
    Form 990-PF (2020)
    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 atbullet1101 PARK AVEWINONA LAKEIN ZIP+4bullet46590
    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 2020, 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 2020?.............
    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 2020, did the foundation have any undistributed income (lines 6d
    and 6e, Part XIII) for tax year(s) beginning before 2020?.............
    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 2020 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 2020.)..................
    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 2020?
    4b
     
    No
    Form 990-PF (2020)
    Form 990-PF (2020)
    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     		214,782 6,275 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    ANDREW GROSSNICKLE CHAIRMAN
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    LISA O'NEILL VICE CHAIRMAN
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    MAX MOCK TREASURER
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    SCOTT TUCKER SECRETARY
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    BECKY ALLES DIRECTOR
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    JESSICA BRICKER DIRECTOR
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    JOE GRAHAM DIRECTOR
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    STEVE GRILL DIRECTOR
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    JILL GROSS DIRECTOR
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    JOELLA HAUSEMANN DIRECTOR
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    RICK KERLIN DIRECTOR
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    ANITA KISHAN DIRECTOR
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    CHAD LARSH DIRECTOR
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    SANDRA PARRA DIRECTOR
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    STEVE ROSS DIRECTOR
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    DR JASMINE SCHLITT DIRECTOR
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    BILL SMITH DIRECTOR
    1.00     		0 0 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    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
    JENNIFER STEWART MARKETING MANAGER
    40.00     		52,984 1,589 0
    1101 PARK AVE
    WINONA LAKE,IN46590
    Total number of other employees paid over $50,000...................bullet 0
    Form 990-PF (2020)
    Form 990-PF (2020)
    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
    WINONA LAKE RESTORATION BUILDING RENOVATIONS 388,345
    28520 CR 50
    NAPPANEE,IN46550
    MARQUETTE ASSOCIATES INVESTMENT CONSULTING 69,000
    180 N LASALLE SUITE 3500
    CHICAGO,IL60601
    CUSTER FURNITURE 60,815
    217 GRANDSVILL AVE
    GRAND RAPIDS,MI49503
    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. 32,983
    2  
    All other program-related investments. See instructions.
    3  
    Total. Add lines 1 through 3.........................bullet32,983
    Form 990-PF (2020)
    Form 990-PF (2020)
    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
    73,015,578
    b
    Average of monthly cash balances.......................
    1b
    406,048
    c
    Fair market value of all other assets (see instructions)................
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    73,421,626
    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
    73,421,626
    4
    Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
    instructions) .............................
    4
    1,101,324
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    72,320,302
    6
    Minimum investment return. Enter 5% of line 5..................
    6
    3,616,015
    Part XI
    Distributable Amount (see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations and certain foreign organizations check here right arrow and do not complete this part.)
    1
    Minimum investment return from Part X, line 6....................
    1
    3,616,015
    2a
    Tax on investment income for 2020 from Part VI, line 5......
    2a
    56,775
    b
    Income tax for 2020. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    56,775
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    3,559,240
    4
    Recoveries of amounts treated as qualifying distributions................
    4
    0
    5
    Add lines 3 and 4............................
    5
    3,559,240
    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
    3,559,240
    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
    3,185,960
    b
    Program-related investments—total from Part IX-B..................
    1b
    32,983
    2
    Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
    purposes...............................
    2
     
    3
    Amounts set aside for specific charitable projects that satisfy the:
    a
    Suitability test (prior IRS approval required)....................
    3a
     
    b
    Cash distribution test (attach the required schedule) .................
    3b
     
    4
    Qualifying distributions. Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
    4
    3,218,943
    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
    0
    6
    Adjusted qualifying distributions. Subtract line 5 from line 4..............
    6
    3,218,943
    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 (2020)
    Form 990-PF (2020)
    Page 9
    Part XIII
    Undistributed Income (see instructions)
    (a)
    Corpus     		(b)
    Years prior to 2019     		(c)
    2019     		(d)
    2020
    1 Distributable amount for 2020 from Part XI, line 7 3,559,240
    2 Undistributed income, if any, as of the end of 2020:
    a Enter amount for 2019 only....... 0
    b Total for prior years:20, 20, 20 0
    3 Excess distributions carryover, if any, to 2020:
    a From 2015...... 982,854
    b From 2016...... 515,855
    c From 2017...... 539,316
    d From 2018...... 624,896
    e From 2019...... 712,716
    fTotal of lines 3a through e........ 3,375,637
    4Qualifying distributions for 2020 from Part
    XII, line 4: bullet$ 3,218,943
    a Applied to 2019, 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 2020 distributable amount..... 3,218,943
    e Remaining amount distributed out of corpus 0
    5 Excess distributions carryover applied to 2020. 340,297 340,297
    (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 3,035,340
    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 2019. Subtract line
    4a from line 2a. Taxable amount—see
    instructions .............     		0
    f Undistributed income for 2020. Subtract
    lines 4d and 5 from line 1. This amount must
    be distributed in 2021 ..........     		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 2015 not
    applied on line 5 or line 7 (see instructions) ...     		642,557
    9Excess distributions carryover to 2021.
    Subtract lines 7 and 8 from line 6a ......     		2,392,783
    10 Analysis of line 9:
    a Excess from 2016.... 515,855
    b Excess from 2017.... 539,316
    c Excess from 2018.... 624,896
    d Excess from 2019.... 712,716
    e Excess from 2020....  
    Form 990-PF (2020)
    Form 990-PF (2020)
    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 2020, 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) 2020 (b) 2019 (c) 2018 (d) 2017
             
    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
    1101 PARK AVE
    WINONA LAKE,IN46590
    (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 (2020)
    Form 990-PF (2020)
    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 ALICIA CENTENO
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,784
    CANCER CARE GRANT ANA MORALES
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,063
    CANCER CARE GRANT ANDY KERR
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,605
    CANCER CARE GRANT ANTHONY HENSEL
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,134
    CANCER CARE GRANT BARBARA SKEANS
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,000
    CANCER CARE GRANT BRAXTON ELLIOT
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 7,050
    CANCER CARE GRANT CARL FINKEN
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,524
    CANCER CARE GRANT CARL POE
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,967
    CANCER CARE GRANT DAVID WEAVER
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,742
    CANCER CARE GRANT DEBBIE WHYBREW
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,459
    CANCER CARE GRANT DELIA NAVARRO
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,100
    CANCER CARE GRANT DONALD BIAS
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,669
    CANCER CARE GRANT DOROTHY SNYDER
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,627
    CANCER CARE GRANT GEORGE HATCHER
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,000
    CANCER CARE GRANT GEORGE YOUNG
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,717
    CANCER CARE GRANT JAMES KECK
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,997
    CANCER CARE GRANT JAMES NEACE
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,100
    CANCER CARE GRANT JAMES OVERBEY
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,325
    CANCER CARE GRANT JEAN ZAJICEK
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 6,000
    CANCER CARE GRANT JIMMY HARTMAN
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,305
    CANCER CARE GRANT JON MAUK
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,217
    CANCER CARE GRANT JONATHAN GOON
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,251
    CANCER CARE GRANT LEI WANG
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,000
    CANCER CARE GRANT MARK DEMSKE
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,000
    CANCER CARE GRANT MAX THOMPSON
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,650
    CANCER CARE GRANT MELISSA FUGATE
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,300
    CANCER CARE GRANT MONICA CAPLES
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,494
    CANCER CARE GRANT NEELEY SCHWINNEN
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,179
    CANCER CARE GRANT PAUL BARTELS
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,500
    CANCER CARE GRANT PAUL HOPKINS
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 5,112
    CANCER CARE GRANT PAULA HAWN
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,200
    CANCER CARE GRANT REAGAN DICE
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 5,602
    CANCER CARE GRANT REBECCA PHEND
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,549
    CANCER CARE GRANT REBECCA VANCE
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,217
    CANCER CARE GRANT RICHARD HARRELL
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,352
    CANCER CARE GRANT RICKY GIBSON
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3,706
    CANCER CARE GRANT ROBERT CRAWFORD
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,500
    CANCER CARE GRANT ROBERT SPRAGUE
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,500
    CANCER CARE GRANT RONNIE BALDRIDGE
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,000
    CANCER CARE GRANT RYAN VANCUREN
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 5,500
    CANCER CARE GRANT SUSAN GARDNER
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4,761
    CANCER CARE GRANT TAMARA NEISWONGER
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,500
    CANCER CARE GRANT TED GILLEM
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,349
    CANCER CARE GRANT TERESA BOYER
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,368
    CANCER CARE GRANT TERRY WALTERS
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2,589
    CANCER CARE GRANT TIM HAND
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1,765
    CANCER CARE GRANT OTHER GRANTS LESS
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 19,149
    CONDITIONAL GRANT HEARTLINE PREGNANCY CENTER
    1515 PROVIDENT DRIVE SUITE 180
    WARSAW,IN46580     		NONE PC PROGRAM FUNDING 54,767
    CONDITIONAL GRANT LIVE WELL KOSCIUSKO
    8546 SOUTH 200 WEST
    CLAYPOOL,IN46510     		NONE PC OPERATIONAL FUNDING 65,437
    CONDITIONAL GRANT KOSCIUSKO HOME CARE & HOSPICE
    1515 PROVIDENT DRIVE STE 250
    WARSAW,IN46581     		NONE PC MEDICATION & DENTAL ASSISTANCE/COMPUTERS 286,474
    CONDITIONAL GRANT GRACE COLLEGE & SEMINARY
    200 SEMINARY DRIVE
    WINONA LAKE,IN46590     		NONE PC LILLY CENTER FOR LAKES & STREAMS RESEARCH 100,639
    CONDITIONAL GRANT ROSE GARDEN RECOVERY COMMUNITY
    72876 CR 29
    SYRACUSE,IN46567     		NONE PC FACILITY RENOVATION 148,288
    CONDITIONAL GRANT BAKER YOUTH CLUB
    1401 EAST SMITH STREET
    WARSAW,IN46580     		NONE PC EXERGAME EQUIPMENT/FITBITS/AED 1,945
    CONDITIONAL GRANT NORTHERN INDIANA HISPANIC HEALTH COALITION
    444 NORTH NAPPANEE STREET
    ELKHART,IN46514     		NONE PC HEALTH SCREENINGS/CLIENT ADVOCAC;Y 40,000
    CONDITIONAL GRANT RIGHT TO LIFE OF NORTH CENTRAL INDIANA
    1906 HAMILTON BLVD
    WINONA LAKE,IN46590     		NONE PC BABYBOX MARKETING CAMPAIGN 7,215
    CONDITIONAL GRANT SERENITY HOUSE INC
    622 EAST FORT WAYNE STREET
    WARSAW,IN46580     		NONE PC FACILITIES RENOVATIONS 55,747
    CONDITIONAL GRANT WARSAW COMMUNITY SCHOOLS
    1 ADMINISTRATIION DRIVE
    WARSAW,IN46580     		NONE PC SUICIDE PREVENTION SPEAKER/QPR TRAINING 14,000
    CONDITIONAL GRANT KOSCIUSKO COUNTY FREE CLINIC
    7822 EAST EPWORTH FOREST ROAD
    NORTH WEBSTER,IN46555     		NONE PC COMPUTER HARDWARE/SOFTWARE 16,047
    CONDITIONAL GRANT KOSCIUSKO HEALTH SERVICES PAVILION
    1515 PROVIDENT DRIVE
    WARSAW,IN46580     		NONE PC BUILDING RENOVATIONS 175,395
    CONDITIONAL GRANT CAMP ALEXANDER MACK
    PO BOX 158
    MILFORD,IN46542     		NONE PC HIGH/LOW ROPES COURSE 65,600
    CONDITIONAL GRANT COMBINED COMMUNITY SERVICES
    1195 MARINERS DRIVE
    WINONA LAKE,IN46582     		NONE PC REFRIGERATION-FREEZER ROOM/EQUIPMENT/COMPUTERS 78,480
    CONDITIONAL GRANT ENDS OF THE EARTH OUTREACH
    PO BOX 2021
    WARSAW,IN46581     		NONE PC COUNT ON ME PROGRAM 2,000
    CONDITIONAL GRANT KOSCIUSKO COUNTY SHELTER FOR ABUSE
    603 NORTH PARKER STREET
    WARSAW,IN46580     		NONE PC GENERATOR 24,966
    CONDITIONAL GRANT QUESTA FOUNDATION
    6502 CONSTITUTION DR
    FORT WAYNE,IN46804     		NONE PC QUESTA SCHOLARS PROGRAM 60,000
    CONDITIONAL GRANT TOWN OF WINONA LAKE
    1310 PARK AVENUE
    WINONA LAKE,IN46590     		NONE PC GREENWAY ENGINEERING 82,780
    CONDITIONAL GRANT TRITON SCHOOL CORPORATION
    100 TRITON DRIVE
    BOURBON,IN46504     		NONE PC TENNIS COURT RESURFACING 75,000
    CONDITIONAL GRANT CARDINAL SERVICES
    504 NORTH BAY DRIVE
    WARSAW,IN46580     		NONE PC GROWING GREAT KIDS CURRICULUM 19,400
    CONDITIONAL GRANT CITY OF WARSAW
    102 SOUTH BUFFALO STREET
    WARSAW,IN46580     		NONE PC MECHANICAL CPR DEVICES/GREENWAY TRAIL STUDY 246,130
    CONDITIONAL GRANT HOUSING OPPORTUNITIES OF WARSAW
    109 WEST CATHERINE STREET
    MILFORD,IN46542     		NONE PC HEALTHY HOMES PROGRAM 2,580
    CONDITIONAL GRANT KOSCIUSKO COUNTY
    121 WEST MAIN STREET
    WARSAW,IN46580     		NONE PC JCAP PROGRAM FUNDING 9,058
    CONDITIONAL GRANT KOSCIUSKO COUNTY COMMUNITY FOUNDATION
    102 EAST MARKET STREET
    WARSAW,IN46580     		NONE PC COUNTYWIDE COMPREHENSIVE PLAN 50,000
    CONDITIONAL GRANT KOSCIUSKO COMMUNITY YMCA
    1305 MARINERS DRIVE
    WARSAW,IN46582     		NONE PC DIABETES PREVENTION PROGRAM 6,796
    CONDITIONAL GRANT LAKE CITY SKI TEAM
    2455 HIDDEN LAKE DRIVE
    WARSAW,IN46580     		NONE PC LEARN TO SKI PROGRAM EQUIPMENT 26,550
    CONDITIONAL GRANT TOWN OF NORTH WEBSTER
    144 SOUTH MAIN STREET
    NORTH WEBSTER,IN46555     		NONE PC COMMUNITIES GRANT 44,878
    CONDITIONAL GRANT JOE'S KIDS
    902 PROVIDENT DRIVE SUITE C
    WARSAW,IN46580     		NONE PC RENT SUBSIDY 41,220
    CONDITIONAL GRANT LAKELAND CHRISTIAN ACADEMY
    1093 SOUTH 250 EAST
    WINONA LAKE,IN46590     		NONE PC NURSE'S OFFICE EQUIPMENT 8,996
    CONDITIONAL GRANTS OTHER GRANTS UNDER 1000
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE PC EQUIPMENT 1,580
    DIRECT GRANT BAKER YOUTH CLUB
    1401 E SMITH ST
    WARSAW,IN46580     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION, OPERATIONAL 2,500
    DIRECT GRANT FELLOWSHIP MISSIONS
    1520 EAST WINONA AVENUE
    WARSAW,IN46580     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION 1,500
    DIRECT GRANT KOSCIUSKO COUNTY COMMUNITY FOUNDATION
    102 EAST MARKET STREET
    WARSAW,IN46580     		NONE PC COVID-19 RAPID RESPONSE FUND 10,000
    DIRECT GRANT KOSCIUSKO COMMUNITY YMCA
    1305 MARINERS DR
    WARSAW,IN46582     		NONE PC OPERATIONAL ASSISTANCE 21,405
    DIRECT GRANT LIVE WELL KOSCIUSKO
    8546 SOUTH 200 WEST
    CLAYPOOL,IN46510     		NONE PC GALLUP POLL STUDY 44,250
    DIRECT GRANT NORTH STAR MEDICAL
    2045 112TH AVE
    HOLLAND,MI49424     		NONE PC AED AND MEDICAL EQUIPMENT FOR MULTIPLE ORGANIZATIONS 5,907
    DIRECT GRANT WARSAW ELKS LODGE
    310 EAST CENTER STREET
    WARSAW,IN46580     		NONE PC NEEDY CHILDREN'S CHRISTMAS PARTY 2,000
    DIRECT GRANTS OTHER GRANTS UNDER 1000
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE PC K21 BOARD OF DIRECTORS DIRECTED DONATION 16,800
    UNCONDITIONAL GRANT BAKER YOUTH CLUB
    1401 E SMITH ST
    WARSAW,IN46580     		NONE PC OPERATIONAL ASSISTANCE 40,000
    UNCONDITIONAL GRANT BIG BROTHERS BIG SISTERS
    1005 WEST RUDISILL BLVD 101
    FORT WAYNE,IN46804     		NONE PC OPERATIONAL ASSISTANCE 5,000
    UNCONDITIONAL GRANT BOWEN CENTER
    2621 EAST JEFFERSON STREET
    WARSAW,IN46580     		NONE PC SYSTEMS OF CARE COORDINATOR 20,000
    UNCONDITIONAL GRANT BRIGHTPOINT
    227 E WASHINGTON BLVD
    FORT WAYNE,IN46804     		NONE PC COVERING KIDS & FAMILIES 20,000
    UNCONDITIONAL GRANT CANCER SERVICES OF NORTHEAST INDIANA
    6316 MUTUAL DRIVE
    FORT WAYNE,IN46825     		NONE PC DIRECT ASSISTANCE / CLIENT ADVOCACY 20,000
    UNCONDITIONAL GRANT COMBINED COMMUNITY SERVICES
    1195 MARINERS DRIVE
    WARSAW,IN46582     		NONE PC WORKSHOPS/PROGRAM INCENTIVES 5,000
    UNCONDITIONAL GRANT EARLY CHILDHOOD ALLIANCE
    3800 NORTH ANTHONY BLVD
    FORT WAYNE,IN46805     		NONE PC OPERATIONAL ASSISTANCE FOR CHILD CARE FOR ESSENTIAL WORKERS 7,805
    UNCONDITIONAL GRANT FELLOWSHIP MISSIONS
    1520 EAST WINONA AVENUE
    WARSAW,IN46580     		NONE PC CAMP CROSLEY RENTAL 30,000
    UNCONDITIONAL GRANT GRACE COLLEGE & SEMINARY
    200 SEMINARY DRIVE
    WINONA LAKE,IN46590     		NONE PC LILLY CENTER OPERATIONAL ASSISTANCE/COVID FUNDING 65,000
    UNCONDITIONAL GRANT KOSCIUSKO COMMUNITY YMCA
    1305 MARINERS DR
    WARSAW,IN46582     		NONE PC OEPRATIONAL ASSISTANCE/YOUTH SPORTS PROGRAMS 56,500
    UNCONDITIONAL GRANT KOSCIUSKO COUNTY COMMUNITY FOUNDATION
    102 EAST MARKET STREET
    WARSAW,IN46580     		NONE PC GOOD SAMARITAN FUND 93,750
    UNCONDITIONAL GRANT KOSCIUSKO COUNTY SHELTER FOR ABUSE
    603 NORTH PARKER STREET
    WARSAW,IN46580     		NONE PC OPERATIONAL ASSISTANCE 20,000
    UNCONDITIONAL GRANT KOSCIUSKO HOME CARE & HOSPICE
    1515 PROVIDENT DRIVE STE 250
    WARSAW,IN46580     		NONE PC OPERATIONAL ASSISTANCE 167,220
    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 EAST 525 NORTH
    WARSAW,IN46582     		NONE PC OPERATIONAL ASSISTANCE 4,000
    UNCONDITIONAL GRANT MCMILLEN CENTER
    600 JIM KELLEY BLVD
    FORT WAYNE,IN46816     		NONE PC HEALTH EDUCATION PROGRAMS 5,000
    UNCONDITIONAL GRANT TOWN OF WINONA LAKE
    1310 PARK AVENUE
    WINONA LAKE,IN46590     		NONE PC PROTECTIVE FACE MASKS 5,625
    UNCONDITIONAL GRANT TOWN OF SYRACUSE
    310 NORTH HUNTINGTON STREET
    SYRACUSE,IN46567     		NONE PC PROTECTIVE FACE MASKS 8,297
    UNCONDITIONAL GRANT TOWN OF PIERCETON
    207 NORTH 1ST STREET
    PIERCETON,IN46562     		NONE PC PROTECTIVE FACE MASKS 2,909
    UNCONDITIONAL GRANT TOWN OF NORTH WEBSTER
    144 SOUTH MAIN STREET
    NORTH WEBSTER,IN46555     		NONE PC PROTECTIVE FACE MASKS 3,771
    UNCONDITIONAL GRANT REAL SERVICES INC
    1151 SOUTH MICHIGAN STREET
    SOUTH BEND,IN46601     		NONE PC MINI RESOURCE LIBRARIES 1,500
    UNCONDITIONAL GRANT ROSE GARDEN RECOVERY COMMUNITY
    PO BOX 571
    SYRACUSE,IN46567     		NONE PC OPERATIONAL ASSISTANCE 3,600
    UNCONDITIONAL GRANT RYAN'S PLACE INC
    PO BOX 73
    GOSHEN,IN46527     		NONE PC OPERATIONAL ASSISTANCE 8,000
    UNCONDITIONAL GRANT TURNING POINT
    225 NORTH MAIN STREET
    NORTH WEBSTER,IN46555     		NONE PC TECHNOLOGY UPGRADE 5,900
    UNCONDITIONAL GRANT OTHER GRANTS UNDER 1000
    1101 PARK AVE
    WINONA LAKE,IN46590     		NONE PC UNCONDITIONAL GRANTS TO ORGANIZATIONS 1,390
    Total .................................bullet 3a 2,681,075
    bApproved for future payment
    Total .................................bullet 3b 0
    Form 990-PF (2020)
    Form 990-PF (2020)
    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 ...........     		    14 390,905  
    4 Dividends and interest from securities....     14 977,125  
    5 Net rental income or (loss) from real estate:
    aDebt-financed property......          
    bNot debt-financed property.....     16 64,537  
    6 Net rental income or (loss) from personal property          
    7 Other investment income.....     14 3,081  
    8 Gain or (loss) from sales of assets other than
    inventory ............     		    18 2,877,980  
    9 Net income or (loss) from special events:          
    10 Gross profit or (loss) from sales of inventory          
    11 Other revenue: a
    b
    c
    d
    e
    12 Subtotal. Add columns (b), (d), and (e).. 0 4,313,628 0
    13Total. Add line 12, columns (b), (d), and (e)..................
    13
    4,313,628
    (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 (2020)
    Form 990-PF (2020)
    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 instructions.
    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 (2020)
    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
    2020
    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) (2020)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020) Page 2
    Name of organization
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
    AKA K21 HEALTH FOUNDATION         		Employer identification number
    35-1187105
    Part I
    Contributors
    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

    		$ 201,248


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    2
    BEAVER DAM UM CHURCH
     
    9798 W 1000 SOUTH
     
    AKRON, IN46910

    		$ 14,000


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    3
    BERTSCH FAMILY CHARITABLE FOUNDATION
     
    PO BOX 1494
     
    WARSAW, IN46581

    		$ 6,000


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    4
    DOUG SCHROCK
     
    711 SOUTH STREET
     
    KEY WEST, FL33040

    		$ 5,000


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

    		$  


    (Complete Part II for noncash contributions.)
    (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) (2020)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020)
    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 $ 201,248 2020-12-31
    (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) (2020)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020)
    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) (2020)
    Additional Data


    Software ID:  
    Software Version:  

    TY 2020 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 19,150 0 0 19,150

    TY 2020 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 2020 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 6,128,634 6,395,237
    FOREIGN BONDS 672,012 706,697

    TY 2020 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 31,076,371 49,951,449

    TY 2020 InvestmentsGovtObligationsSch
    Name:
    KOSCIUSKO 21ST CENTURY FOUNDATION INC
     
    AKA K21 HEALTH FOUNDATION
    EIN:
    35-1187105
    US Government Securities - End of Year Book Value:

    6,051,741
    US Government Securities - End of Year Fair Market Value:

    6,053,922
    State & Local Government Securities - End of Year Book Value:


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


    0


    TY 2020 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 57,995 0 57,995 57,995
    LAND IMPROVEMENTS 311,605 148,762 162,843 162,843
    LEASEHOLD IMPROVEMENTS 969,226 561,335 407,891 407,891
    BUILDING 1,887,688 277,393 1,610,295 1,610,295

    TY 2020 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 2,450,568 3,232,633
    HEDGE FUND FMV 4,304,941 3,993,789
    GLOBAL MANAGED VOLATILITY FMV 2,726,823 4,126,027
    US EQUITY INDEX PUTWRITE FUND LLC FMV 4,134,877 4,349,903
    PRIVATE EQUITY FMV 379,412 412,335

    TY 2020 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 122,885 8,566 114,319 114,319


    TY 2020 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 788,792 788,792 788,792
    RECEIVABLE - OTHER 1,186 472 472


    TY 2020 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 32,983 0 0 0
    FUNDRAISING EXPENSES 15,824 0 0 15,824
    INSURANCE 8,817 0 0 11,496
    MARKETING 28,940 0 0 28,940
    MISCELLANEOUS EXPENSE 50,340 7,482 0 42,858


    TY 2020 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 3,081 3,081  


    TY 2020 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 241,391 296,023


    TY 2020 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 229,069 229,069 0 0


    TY 2020 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 111,407 0 0 0
    FOREIGN INCOME TAXES 47 47 0 0