Form990-PF

Department of the Treasury
Internal Revenue Service

Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
right arrowDo not enter social security numbers on this form as it may be made public.
right arrowGo to www.irs.gov/Form990PF for instructions and the latest information.
OMB No. 1545-0047
2023
Open to Public Inspection
For calendar year 2023, or tax year beginning 01-01-2023 , and ending 12-31-2023
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 right arrow
G Check all that apply:

D 1. Foreign organizations, check here............. right arrow
2. Foreign organizations meeting the 85%
test, check here and attach computation ... right arrow
E right arrow
H Check type of organization:
F right arrow
I Fair market value of all assets at end
of year (from Part II, col. (c),
line 16)right arrow$80,856,575J 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) 217,378
2 Check right arrow.............
3 Interest on savings and temporary cash investments 746,048 746,048  
4 Dividends and interest from securities... 866,015 866,015  
5a Gross rents............ 244,733 244,733  
b Net rental income or (loss) 96,584
6a Net gain or (loss) from sale of assets not on line 10 2,866,079
b Gross sales price for all assets on line 6a 42,882,084
7 Capital gain net income (from Part IV, line 2)... 2,866,079
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
List of Attached Documents:
// Content
1,473 1,473 0
12 Total. Add lines 1 through 11........ 4,941,726 4,724,348 0
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 248,990 0 0 248,990
14 Other employee salaries and wages...... 113,173 0 0 84,170
15 Pension plans, employee benefits....... 29,817 0 0 29,817
16a Legal fees (attach schedule).........        
b Accounting fees (attach schedule)....... Click to see attachment
List of Attached Documents:
// Content
21,020 0 0 21,020
c Other professional fees (attach schedule).... Click to see attachment
List of Attached Documents:
// Content
301,539 301,539 0 0
17 Interest...............        
18 Taxes (attach schedule) (see instructions)... Click to see attachment
List of Attached Documents:
// Content
140,604 0 0 0
19 Depreciation (attach schedule) and depletion... 199,670 143,430 0
20 Occupancy.............. 36,394 0 0 36,394
21 Travel, conferences, and meetings....... 20,401 0 0 20,401
22 Printing and publications.......... 3,104 0 0 3,104
23 Other expenses (attach schedule)....... Click to see attachment
List of Attached Documents:
// Content
185,136 4,719 0 180,658
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 1,299,848 449,688 0 624,554
25 Contributions, gifts, grants paid....... 4,635,712 4,651,498
26 Total expenses and disbursements. Add lines 24 and 25 5,935,560 449,688 0 5,276,052
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements -993,834
b Net investment income (if negative, enter -0-) 4,274,660
c Adjusted net income (if negative, enter -0-)... 0
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X Form 990-PF (2023)
Form 990-PF (2023)
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......... 1,368,644 604,386 604,386
3 Accounts receivable right arrow  
Less: allowance for doubtful accounts right arrow        
4 Pledges receivable right arrow  
Less: allowance for doubtful accounts right arrow        
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) right arrow  
Less: allowance for doubtful accounts right arrow        
8 Inventories for sale or use..............      
9 Prepaid expenses and deferred charges.......... 10,260 10,501 10,501
10a Investments—U.S. and state government obligations (attach schedule) 6,915,768 Click to see attachment
List of Attached Documents:
// Content
6,146,207 		6,167,805
b Investments—corporate stock (attach schedule)....... 26,171,276 Click to see attachment
List of Attached Documents:
// Content
25,461,574 		40,929,700
c Investments—corporate bonds (attach schedule)....... 5,829,440 Click to see attachment
List of Attached Documents:
// Content
6,278,907 		6,233,431
11 Investments—land, buildings, and equipment: basis right arrow2,355,854
Less: accumulated depreciation (attach schedule) right arrow1,407,127 1,064,573 Click to see attachment
List of Attached Documents:
// Content
948,727 		948,727
12 Investments—mortgage loans.............      
13 Investments—other (attach schedule).......... 21,215,986 Click to see attachment
List of Attached Documents:
// Content
22,342,532 		24,963,495
14 Land, buildings, and equipment: basis right arrow1,067,482
Less: accumulated depreciation (attach schedule) right arrow214,697 906,522 Click to see attachment
List of Attached Documents:
// Content
852,785 		852,785
15 Other assets (describe right arrow) Click to see attachment
List of Attached Documents:
// Content
194,081 		Click to see attachment
List of Attached Documents:
// Content
145,745 		Click to see attachment
List of Attached Documents:
// Content
145,745
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 63,676,550 62,791,364 80,856,575
Liabilities 17 Accounts payable and accrued expenses.......... 3,585 46,055
18 Grants payable................. 270,399 254,609
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 right arrow) Click to see attachment
List of Attached Documents:
// Content
169,138 		Click to see attachment
List of Attached Documents:
// Content
251,106
23 Total liabilities (add lines 17 through 22)......... 443,122 551,770
Net Assets or Fund Balances Foundations that follow FASB ASC 958, check here right arrow
and complete lines 24, 25, 29 and 30.
24 Net assets without donor restrictions........... 61,756,407 61,447,503
25 Net assets with donor restrictions............ 1,477,021 792,091
Foundations that do not follow FASB ASC 958, check here right arrow
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)..... 63,233,428 62,239,594
30 Total liabilities and net assets/fund balances (see instructions). 63,676,550 62,791,364
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
63,233,428
2
Enter amount from Part I, line 27a .....................
2
-993,834
3
Other increases not included in line 2 (itemize) right arrow
3
0
4
Add lines 1, 2, and 3 ..........................
4
62,239,594
5
Decreases not included in line 2 (itemize) right arrow
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
62,239,594
Form 990-PF (2023)
Form 990-PF (2023)
Page 3
Part IV
Capital Gains and Losses for Tax on Investment Income
(a) List and describe the kind(s) of property sold (e.g., real estate,
2-story brick warehouse; or common stock, 200 shs. MLC Co.)		 (b)
How acquired
P—Purchase
D—Donation 		(c)
Date acquired
(mo., day, yr.) 		(d)
Date sold
(mo., day, yr.)
1 a SALE OF SECURITIES      
b
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 42,882,084   40,016,005 2,866,079
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       2,866,079
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 2,866,079
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
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 right arrow 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) 1 59,418
b All other domestic foundations enter 1.39% (0.0139) of line 27b. Exempt foreign organizations enter 4% (0.04) 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 59,418
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 59,418
6 Credits/Payments:
a 2023 estimated tax payments and 2022 overpayment credited to 2023 6a 47,958
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 47,958
8 Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached. Click to see attachment
List of Attached Documents:
// Content
8 545
9 Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......right arrow 9 12,005
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...right arrow 10  
11 Enter the amount of line 10 to be: Credited to 2024 estimated taxright arrow   Refundedright arrow 11  
Form 990-PF (2023)
Form 990-PF (2023)
Page 4
Part VI-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. right arrow$ 0(2) On foundation managers.right arrow$ 0
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.right arrow$ 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:
round bullet By language in the governing instrument, or
round bullet 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 XIV..................................
7
Yes
 
8a
Enter the states to which the foundation reports or with which it is registered (see instructions)
right arrowIN
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 2023 or the taxable year beginning in 2023? See the instructions for Part XIII.
If "Yes," complete Part XIII .............................
9
 
No
10
Did any persons become substantial contributors during the tax year? If "Yes," attach a schedule listing their names
and addresses. ...............................
10
 
No
11
At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the
meaning of section 512(b)(13)? If "Yes," attach schedule. See 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 addressright arrowWWW.K21HEALTHFOUNDATION.ORG
14
The books are in care ofright arrowRICH HADDAD Telephone no.right arrow (574) 269-5188

Located atright arrow1101 PARK AVEWINONA LAKEIN ZIP+4right arrow46590
15
Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041 —check here .........right arrow
and enter the amount of tax-exempt interest received or accrued during the year ........right arrow
15
 
16 At any time during calendar year 2023, 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 right arrow
Form 990-PF (2023)
Form 990-PF (2023)
Page 5
Part VI-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? ...........
1a(1)
 
No
(2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from)
a disqualified person? ..............................
1a(2)
 
No
(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? ...........
1a(3)
 
No
(4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person? ............
1a(4)
Yes
 
(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)? ......................
1a(5)
 
No
(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.) ...............
1a(6)
 
No
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
c
Organizations relying on a current notice regarding disaster assistance check here ........right arrow
d
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 2023? .............
1d
 
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 2023, did the foundation have any undistributed income (Part XII, lines 6d
and 6e) for tax year(s) beginning before 2023?....................
2a
 
No
If "Yes," list the years right arrow20, 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.
right arrow20, 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? ..............................
3a
 
No
b
If "Yes," did it have excess business holdings in 2023 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 2023.) .....................
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 2023? ..
4b
 
No
Form 990-PF (2023)
Form 990-PF (2023)
Page 6
Part VI-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))? ..........
5a(1)
 
No
(2) Influence the outcome of any specific public election (see section 4955); or to carry
on, directly or indirectly, any voter registration drive? ....................
5a(2)
 
No
(3) Provide a grant to an individual for travel, study, or other similar purposes? .............
5a(3)
 
No
(4) Provide a grant to an organization other than a charitable, etc., organization described
in section 4945(d)(4)(A)? See instructions ........................
5a(4)
 
No
(5) Provide for any purpose other than religious, charitable, scientific, literary, or
educational purposes, or for the prevention of cruelty to children or animals? .............
5a(5)
 
No
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
 
 
c
Organizations relying on a current notice regarding disaster assistance check .........right arrow
d
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? .................
5d
 
 
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? .............................
6a
 
No
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?
7a
 
No
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? .........................
8
 
No
Part VII
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 		242,466 6,524 0
1101 PARK AVE
WINONA LAKE,IN46590
BILL SMITH CHAIRMAN
1.00 		0 0 0
1101 PARK AVE
WINONA LAKE,IN46590
JESSICA BRICKER VICE CHAIRMAN
1.00 		0 0 0
1101 PARK AVE
WINONA LAKE,IN46590
LISA O'NEILL TREASURER
1.00 		0 0 0
1101 PARK AVE
WINONA LAKE,IN46590
JILL GROSS SECRETARY
1.00 		0 0 0
1101 PARK AVE
WINONA LAKE,IN46590
TRICIA GALL 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
ANDREW GROSSNICKLE 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
KELLY KAASE 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
DR CAITLIN RYSER 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
MATTHEW SHAW DIRECTOR
1.00 		0 0 0
1101 PARK AVE
WINONA LAKE,IN46590
JERRY YEAGER 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 		60,250 1,770 0
1101 PARK AVE
WINONA LAKE,IN46590
ANGELA SUMMERS OFFICE MANAGER
40.00 		52,923 1,558 0
1101 PARK AVE
WINONA LAKE,IN46590
Total number of other employees paid over $50,000...................right arrow 0
Form 990-PF (2023)
Form 990-PF (2023)
Page 7
Part VII
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
ROBINSON CONSTRUCTION CONSTRUCTION 935,526
445 E 200 NORTH
WARSAW,IN46582
R YODER CONSTRUCTION CONSTRUCTION 652,976
27453 COUNTY LINE RD 150
NAPPANEE,IN46550
G&G HAULING AND EXCAVATING CONSTRUCTION 280,721
115 N COLUMBIA ST
WARSAW,IN46580
BUTTTIMMONS CONSTRUCTION CONSTRUCTION 200,000
6635 E 950 NORTH
SYRACUSE,IN46567
MIDSTATES RECREATION CONSTRUCTION 108,084
1279 HAZELTON-ETNA RD SW
PATASKALA,OH43062
Total number of others receiving over $50,000 for professional services.............right arrow0
Part VIII-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 VIII-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  
2  
All other program-related investments. See instructions.
3  
Total. Add lines 1 through 3.........................right arrow0
Form 990-PF (2023)
Form 990-PF (2023)
Page 8
Part IX
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
76,528,485
b
Average of monthly cash balances.......................
1b
468,215
c
Fair market value of all other assets (see instructions)................
1c
0
d
Total (add lines 1a, b, and c).........................
1d
76,996,700
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
76,996,700
4
Cash deemed held for charitable activities. Enter 1.5% (0.015) of line 3 (for greater amount, see
instructions) .............................
4
1,154,951
5
Net value of noncharitable-use assets. Subtract line 4 from line 3. ............
5
75,841,749
6
Minimum investment return. Enter 5% (0.05) of line 5................
6
3,792,087
Part X
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 IX, line 6..................
1
3,792,087
2a
Tax on investment income for 2022 from Part V, line 5.......
2a
59,418
b
Income tax for 2022. (This does not include the tax from Part V.) ...
2b
 
c
Add lines 2a and 2b............................
2c
59,418
3
Distributable amount before adjustments. Subtract line 2c from line 1............
3
3,732,669
4
Recoveries of amounts treated as qualifying distributions................
4
0
5
Add lines 3 and 4............................
5
3,732,669
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 XII, line 1 ...
7
3,732,669
Part XI
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
5,276,052
b
Program-related investments—total from Part VIII-B..................
1b
0
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 XII, line 4. .......
4
5,276,052
Form 990-PF (2023)
Form 990-PF (2023)
Page 9
Part XII
Undistributed Income (see instructions)
(a)
Corpus 		(b)
Years prior to 2022 		(c)
2022 		(d)
2023
1 Distributable amount for 2023 from Part X, line 7 3,732,669
2 Undistributed income, if any, as of the end of 2022:
a Enter amount for 2022 only....... 0
b Total for prior years:20 , 20, 20 0
3 Excess distributions carryover, if any, to 2022:
a From 2018...... 624,896
b From 2019...... 712,716
c From 2020......  
d From 2021......  
e From 2022...... 555,735
f Total of lines 3a through e ........ 1,893,347
4Qualifying distributions for 2023 from Part
XI, line 4: right arrow$ 5,276,052
a Applied to 2022, 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 2023 distributable amount..... 3,732,669
e Remaining amount distributed out of corpus 1,543,383
5 Excess distributions carryover applied to 2023. 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 3,436,730
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 2022. Subtract line
4a from line 2a. Taxable amount—see
instructions ............. 		0
f Undistributed income for 2023. Subtract
lines 4d and 5 from line 1. This amount must
be distributed in 2024 .......... 		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 2018 not
applied on line 5 or line 7 (see instructions) ... 		624,896
9 Excess distributions carryover to 2024.
Subtract lines 7 and 8 from line 6a ...... 		2,811,834
10 Analysis of line 9:
a Excess from 2019.... 712,716
b Excess from 2020....  
c Excess from 2021....  
d Excess from 2022.... 555,735
e Excess from 2023.... 1,543,383
Form 990-PF (2023)
Form 990-PF (2023)
Page 10
Part XIII
Private Operating Foundations (see instructions and Part VI-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 2023, enter the date of the ruling ...... right arrow
 
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 IX for each
year listed .......... 		Tax year Prior 3 years (e) Total
(a) 2023 (b) 2022 (c) 2021 (d) 2020
         
b 85% (0.85) of line 2a .........          
c Qualifying distributions from Part XI,
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 IX, 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 XIV
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 right arrow
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 (2023)
Form 990-PF (2023)
Page 11
Part XIV
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

AED EQUIPMENT GRANTS

1101 PARK AVE
WINONA LAKE,IN46590 		NONE GOV EQUIPMENT 32,735

AGAITAS

1945 PHEASANT RIDGE DRIVE
WARSAW,IN46580 		NONE PC OPERATIONAL FUNDING 18,000

AGAITAS

1945 PHEASANT RIDGE DRIVE
WARSAW,IN46580 		NONE PC EQUIPMENT 15,000

AGAITAS

710 PARK AVE
WINONA LAKE,IN46590 		NONE PC OPERATING SUPPORT 2,000

BAKER YOUTH CLUB

1401 E SMITH ST
WARSAW,IN46580 		NONE PC OPERATIONAL ASSISTANCE 50,000

BAKER YOUTH CLUB

1400 E SMITH ST
WARSAW,IN46580 		NONE PC OPERATING SUPPORT 2,500

BIG BROTHERS BIG SISTERS

1005 WEST RUDISILL BLVD
FORT WAYNE,IN46807 		NONE PC OPERATIONAL ASSISTANCE 5,000

BRIGHTPOINT

227 E WASHINGTON BLVD
FORT WAYNE,IN46804 		NONE PC COVERING KIDS & FAMILIES 20,000

CAMP ALEXANDER MACK

1195 MARINERS DRIVE
WARSAW,IN46582 		NONE PC OPERATING SUPPORT 1,000
CANCER CARE GRANTS


1101 PARK AVE
WINONA LAKE,IN46590 		NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 148,606

CANCER SERVICES OF NORTHEAST INDIANA

6316 MUTUAL DRIVE
FORT WAYNE,IN46825 		NONE PC DIRECT ASSISTANCE / CLIENT ADVOCACY 40,000

CARDINAL SERVICES

504 N BAY ST
WARSAW,IN46580 		NONE PC FACILITY RENOVATION 716,385

CITY OF WARSAW

2191 E FORT WAYNE ST
WARSAW,IN46580 		NONE GOV DIVE TEAM EQUIPMENT/CARES EQUIPMENT 56,493

COMBINED COMMUNITY SERVICES

1195 MARINERS DRIVE
WARSAW,IN46582 		NONE PC PROGRAM SUPPORT/STRATEGIC PLANNING 93,835

COMMUNITY TRANSPORTATION NETWORK

5601 INDUSTRIAL RD
FORT WAYNE,IN46825 		NONE PC TRANSPORTATION STUDY 10,000

ETNA GREEN FIRE DEPARTMENT

PO BOX 86
ETNA GREEN,IN46524 		NONE GOV PAGERS EQUIPMENT 14,713

FELLOWSHIP MISSIONS

1520 E WINONA AVE
WARSAW,IN46580 		NONE PC ADDICTION RECOVERY PROGRAM/FEASIBILITY STUDY 38,000

FELLOWSHIP MISSIONS

1520 EAST WINONA AVENUE
WARSAW,IN46580 		NONE PC OPERATING SUPPORT 1,000

GRACE COLLEGE & SEMINARY

1 LANCER WAY
WINONA LAKE,IN46590 		NONE PC LAKES RESEARCH AND MONITORING 154,140

GRACE COLLEGE & SEMINARY

1 LANCER WAY
WINONA LAKE,IN46590 		NONE PC LILLY CENTER OPERATIONAL ASSISTANCE 20,000

HABITAT FOR HUMANITY OF KOSCIUSKO CTY

PO BOX 1913
WARSAW,IN46580 		NONE PC TRAILER AND EQUIPMENT 17,246

HEARTLINE PREGNANCY CENTER

1515 PROVIDENT DRIVE SUITE 180
WARSAW,IN46580 		NONE PC PROGRAM FUNDING 22,264

HOPE'S HARBOR

7922 WEST JEFFERSON BLVD
FORT WAYNE,IN46804 		NONE PC OPERATIONAL ASSISTANCE 12,500

IVY TECH FOUNDATION

2545 SILVEUS CROSSING
WARSAW,IN46580 		NONE PC HEALTH EDUCATION EQUIPMENT 17,460

JOE'S KIDS

902 PROVIDENT DRIVE SUITE C
WARSAW,IN46580 		NONE PC RENT SUBSIDY/FACILITY RENOVATION 94,612

KCV CYCLING CLUB

PO BOX 325
WINONA LAKE,IN46590 		NONE PC TRAINING 30,756

KOSCIUSKO CARES

1515 PROVIDENT DRIVE STE 240
WARSAW,IN46580 		NONE PC PROGRAM SUPPORT 5,000

KOSCIUSKO COMMUNITY YMCA

1305 MARINERS DRIVE
WARSAW,IN46582 		NONE PC FACILITY RENOVATION 639,690

KOSCIUSKO COMMUNITY YMCA

1305 MARINERS DR
WARSAW,IN46582 		NONE PC PROGRAM AND HEALTH SCREENINGS 29,365

KOSCIUSKO COUNTY COMMUNITY FOUNDATION

102 EAST MARKET STREET
WARSAW,IN46580 		NONE PC GOOD SAMARITAN FUND/FUNDING PROGRAM 112,500

KOSCIUSKO HOME CARE & HOSPICE

1515 PROVIDENT DRIVE STE 250
WARSAW,IN46580 		NONE PC MEDICATION & DENTAL ASSISTANCE 258,122

KOSCIUSKO HOME CARE & HOSPICE

1515 PROVIDENT DRIVE STE 250
WARSAW,IN46580 		NONE PC OPERATIONAL ASSISTANCE 40,700

LAKE CITY SKIERS

2455 HIDDEN LAKE DR
WARSAW,IN46580 		NONE PC SAFETY EQUIPMENT 2,155

LIFETOUCH MINISTRIES

PO BOX 253
WINONA LAKE,IN46590 		NONE PC COMPUTER EQUIPMENT 4,310

LIVE WELL KOSCIUSKO

8546 SOUTH 200 WEST
CLAYPOOL,IN46510 		NONE PC OPERATIONAL FUNDING 95,850

LIVE WELL KOSCIUSKO

8546 SOUTH 200 WEST
CLAYPOOL,IN46510 		NONE PC OPERATIONAL FUNDING 31,950

LOST SPARROWS

PO BOX 751
WINONA LAKE,IN46590 		NONE PC CONFERENCE 20,000

LOST SPARROWS

PO BOX 751
WINONA LAKE,IN46590 		NONE PC OPERATING SUPPORT 3,000

MCMILLEN CENTER

600 JIM KELLEY BLVD
FORT WAYNE,IN46816 		NONE PC HEALTH EDUCATION PROGRAMS 10,000

NW FIRE DEPARTMENT

202 N MAIN ST
NORTH WEBSTER,IN46555 		NONE GOV EMERGENCY TRAINING EQUIPMENT 80,128

NW YOUTH LEAGUE

PO BOX 33
NORTH WEBSTER,IN46555 		NONE PC FIELD AND PRACTICE AREA IMPROVEMENT 39,289

OTHER GRANTS LESS THAN 1000

1101 PARK AVE
WINONA LAKE,IN46590 		NONE   OPERATING SUPPORT 8,228

OUR LADY OF GUADALUPE CHURCH

PO BOX 1136
WARSAW,IN46580 		NONE PC OPERATING SUPPORT 1,000

QUESTA FOUNDATION

6502 CONSTITUTION DR
FORT WAYNE,IN46804 		NONE PC SCHOLAR'S PROGRAM 100,000

REAL SERVICES

1151 S MICHIGAN ST
SOUTH BEND,IN46601 		NONE PC PROGRAM SUPPORT 3,400

RILEY CHILDREN'S FOUNDATION

500 N MERIDIAN ST
INDIANAPOLIS,IN46204 		NONE PC PROGRAM SUPPORT 1,000

RONALD MCDONALD HOUSE CHARITIES

11109 PARKVIEW PLAZA DR
FORT WAYNE,IN46845 		NONE PC MOBILE CLINIC AND OPERATING SUPPORT 7,000

ROSE GARDEN RECOVERY COMMUNITY

72876 CR 29
SYRACUSE,IN46567 		NONE PC FACILITY RENOVATION 75,136

RYAN'S PLACE

118 S MAIN ST
GOSHEN,IN46528 		NONE PC PROGRAM SUPPORT 8,000

SEWARD TOWNSHIP

9177 S 600 W
BOURBON,IN46510 		NONE GOV GENERATOR 2,000

SIDNEY JACKSON TOWNSHIP VOLUNTEER FIRE DEPARTMENT

103 E CENTER STREET
SIDNEY,IN46562 		NONE PC COMMUNICATIONS EQUIPMENT 5,498

STILLWATER HOSPICE

5910 HOMESTEAD RD
FORT WAYNE,IN46814 		NONE PC MERGER TRANSITIONAL EXPENSES 130,492

SYRACUSE WAWASEE PARK FOUNDATION

1013 N LONG DR
SYRACUSE,IN46567 		NONE PC PARK RENOVATION 108,084

SYRACUSE WAWASEE PARK FOUNDATION

1013 N LONG DR
SYRACUSE,IN46567 		NONE PC TRAIL FEASIBILITY PLANNING 15,000

THE COMMUNITY NEST

PO BOX 751
WINONA LAKE,IN46590 		NONE PF OPERATING SUPPORT 1,000

THE WATERSHED FOUNDATION

PO BOX 55
NORTH WEBSTER,IN46555 		NONE PC OPERATING SUPPORT 1,500

TOWN OF LEESBURG

PO BOX 372
LEESBURG,IN46538 		NONE GOV PATHWAY CONSTRUCTION 200,000

TOWN OF SILVER LAKE

PO BOX 128
NORTH WEBSTER,IN46555 		NONE GOV EQUIPMENT 143,564

TOWN OF WINONA LAKE

1590 PARK AVENUE
WINONA LAKE,IN46590 		NONE GOV PICKLEBALL COURTS 85,500

TOWN OF WINONA LAKE

1310 PARK AVENUE
WINONA LAKE,IN46590 		NONE GOV PICKLEBALL COURTS/AED EQUIPMENT & TRAINING 2,000

TURNING POINT

225 N MAIN ST
NORTH WEBSTER,IN46555 		NONE PC EQUIPMENT 4,036

WAGON WHEEL THEATRE INC

2515 E CENTER ST
WARSAW,IN46580 		NONE PC OPERATING SUPPORT 1,000

WARRIORS SWIM INC

PO BOX 128
NORTH WEBSTER,IN46555 		NONE PC EQUIPMENT 2,783

WARSAW HEALTH EXPENSES

1101 PARK AVE
WINONA LAKE,IN46590 		NONE PC PARK DEVELOPMENT ALONG CENTER LAKE 731,203

WAWASEE COMMUNITY SCHOOLS

5745 N 750 E
NORTH WEBSTER,IN46555 		NONE GOV DISC GOLF COURSE 5,270

WINONA LAKE POLICE DEPARTMENT

PO BOX 341
WINONA LAKE,IN46590 		NONE GOV OPERATING SUPPORT 2,500
Total .................................right arrow 3a 4,651,498
bApproved for future payment
Total ................................. right arrow 3b 0
Form 990-PF (2023)
Form 990-PF (2023)
Page 12
Part XV-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 ........... 		    14 746,048  
4 Dividends and interest from securities ....     14 866,015  
5 Net rental income or (loss) from real estate:
aDebt-financed property......          
bNot debt-financed property.....     16 96,584  
6 Net rental income or (loss) from personal property          
7 Other investment income .....     01 1,473  
8 Gain or (loss) from sales of assets other than
inventory ............ 		    18 2,866,079  
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 4,576,199 0
13Total. Add line 12, columns (b), (d), and (e)..................
13
4,576,199
(See worksheet in line 13 instructions to verify calculations.)
Part XV-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 XV-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 (2023)
Form 990-PF (2023)
Page 13
Part XVI
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.
right arrow right arrow
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 Check if self-
employed right arrow		 PTIN
Firm's name SmallBullet
 Firm's EIN SmallBullet
Firm's address SmallBullet


 Phone no.
Form 990-PF (2023)
Additional Data


Software ID:  
Software Version:  


Form 990PF - Special Condition Description:
Special Condition Description
Schedule B
(Form 990)
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
2023
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) (2023)
Schedule B (Form 990) (2023) 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
BEAVER DAM UNITED METHODIST CHURCH
 
9798 WEST 1000 SOUTH
 
AKRON, IN46910

$ 34,000


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
2
MR AND MRS DOUGLAS SCHROCK
 
711 SOUTH STREET
 
KEY WEST, FL33040

$ 10,000


(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
ERS WIRELESS
 
PO BOX 110
 
LIGONIER, IN46767

$ 5,500


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
5
LUTHERAN KOSCIUSKO HOSPITAL
 
PO BOX 11748
 
FORT WAYNE, IN46860

$ 5,000


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
6
DONALD GUNDEN
 
64874 ORCHARD DRIVE
 
GOSHEN, IN46526

$ 5,000


(Complete Part II for noncash contributions.)
Schedule B (Form 990) (2023)
Schedule B (Form 990) (2023)
Page 3
Name of organization
KOSCIUSKO 21ST CENTURY FOUNDATION INC
AKA K21 HEALTH FOUNDATION 		Employer identification number

35-1187105
Part II
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a)
No. from Part I 		(b)
Description of noncash property given 		(c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
(a)
No. from Part I 		(b)
Description of noncash property given 		(c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
(a)
No. from Part I 		(b)
Description of noncash property given 		(c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
(a)
No. from Part I 		(b)
Description of noncash property given 		(c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
(a)
No. from Part I 		(b)
Description of noncash property given 		(c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
(a)
No. from Part I 		(b)
Description of noncash property given 		(c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
Schedule B (Form 990) (2023)
Schedule B (Form 990) (2023)
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) (2023)
Additional Data


Software ID:  
Software Version:  

TY 2023 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 21,020 0 0 21,020

TY 2023 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 RESIDENTS 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 APPLICATION CAN BE ACCESSED THROUGH AN ONLINE PROCESS AT WWW.K21HEALTHFOUNDATION.ORG UNDER "APPLY" TAB. GRANT APPLICATIONS ARE ACCEPTED 4 TIMES EACH YEAR. APPLICATIONS RECEIVED AFTER THE QUARTERLY DEADLINE DATES WILL BE HELD UNTIL THE NEXT GRANT CYCLE.FOR ASSISTANCE COMPLETING THE APPLICATION CONTACT: GRANT MANAGER JENNIFER STEWART, AT 574.269.5188 OR JENNIFER@K21HEALTHFOUNDATION.ORG.LINE 2C, ANY SUBMISSION DEADLINES:SUBMISSION DEADLINES ARE FEB 1ST, MAY 1ST, AUG 1ST, AND NOV 1ST.LINE 2D, RESTRICTIONS AND QUALIFICATIONS ON AWARDS:GRANTEES MUST MEET THE FOLLOWING REQUIREMENTS:A. NON-PROFIT AGENCY WITH VERIFIED IRS TAX-EXEMPT STATUS, A PUBLIC SCHOOL SYSTEM, OR A GOVERNMENT AGENCY.B. BE IN GOOD STANDING WITH THE INDIANA SECRETARY OF STATE AS INDICATED IN A BUSINESS ENTITY REPORT.C. BYLAWS REQUIRING TERM LIMITS AND A ROTATING BOARD OF DIRECTORS IS STRONGLY ENCOURAGED.TO QUALIFY FOR A GRANT FROM K21, REQUESTS MUST MEET THE FOLLOWING REQUIREMENTS:--THE PROJECT, PROGRAM, OR SERVICE FOR WHICH YOU ARE SEEKING FUNDING MUST BENEFIT THE RESIDENTS OF KOSCIUSKO COUNTY.--THE IMPACT MUST ADDRESS HEALTH AND WELLNESS ISSUES FOR OUR COMMUNITY. THE PRIORITIES FOR FUNDING CONSIDERATION FOCUS ON AREAS IDENTIFIED IN THE MISSION STATEMENT:--DIRECT HEALTH SERVICES--HEALTH PREVENTION SERVICES--HEALTHY LIVING OPPORTUNITIES
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 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 2023 THE CANCER CARE FUND PROVIDED FINANCIAL ASSISTANCE ALMOST 80 KOSCIUSKO COUNTY CANCER PATIENTS AND THEIR FAMILIES. THE FUND DISBURSED APPROXIMATELY $149,000 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 RECEIVES APPROVAL FOR ALL NEW CLIENT ASSISTANCE BY A SEVEN-PERSON CANCER CARE COMMITTEE AND COLLABORATES WITH A LEAST ONE OF THE COMMITTEE MEMBERS FOR ANY ONGOING ASSISTANCE PROVIDED PREVIOUS APPROVED CLIENTS. FOR APPLICATION ASSISTANCE CONTACT LAURA DEAL-DECKER AT 574.372.3500 OR LAURA@KOSHELPCENTER.ORG.LINE 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 2023 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 5,549,495 5,536,173
FOREIGN BONDS 729,412 697,258

TY 2023 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 25,461,574 40,929,700

TY 2023 InvestmentsGovtObligationsSch
Name:
KOSCIUSKO 21ST CENTURY FOUNDATION INC
 
AKA K21 HEALTH FOUNDATION
EIN:
35-1187105
US Government Securities - End of Year Book Value:

6,146,207
US Government Securities - End of Year Fair Market Value:

6,167,805
State & Local Government Securities - End of Year Book Value:


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


0


TY 2023 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 IMPROVEMENTS 323,126 199,132 123,994 123,994
LEASEHOLD IMPROVEMENTS 985,289 419,878 565,411 565,411
BUILDING 1,023,544 788,117 235,427 235,427
LAND 23,895 0 23,895 23,895

TY 2023 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 1,290,089 2,331,874
HEDGE FUND FMV 4,762,559 3,523,369
GLOBAL MANAGED VOLATILITY FMV 1,961,250 3,505,616
US EQUITY INDEX PUTWRITE FUND LLC FMV 4,917,162 4,519,991
PRIVATE EQUITY FMV 1,528,503 2,065,059
INFRASTRUCTURE INVESTMENTS FMV 4,725,127 5,135,674
INTERNATIONAL ROLLOVER FUND FMV 3,157,842 3,881,912

TY 2023 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
LAND 34,100 0 34,100 34,100
OFFICE & COMPUTER EQUIPMENT 150,770 94,591 56,179 56,179
BUILDING 882,612 120,106 762,506 762,506


TY 2023 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 185,240 142,201 142,201
RECEIVABLE - OTHER 1,212 3,544 3,544
RECEIVABLE - TAX REFUND 7,629 0 0


TY 2023 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
FUNDRAISING EXPENSES 22,499 0 0 22,499
INSURANCE 10,964 0 0 11,205
MARKETING 104,830 0 0 104,830
MISCELLANEOUS EXPENSE 46,843 4,719 0 42,124


TY 2023 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 1,473 1,473  


TY 2023 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 169,138 251,106


TY 2023 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 301,539 301,539 0 0


TY 2023 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 140,604 0 0 0