2023-05-09T15:15:56-05:00 2022-12-31 351178661 BLUE & CO LLC 500 N MERIDIAN ST SUITE 200 INDIANAPOLIS IN 46204 990PF 2022-01-01 351187105 KOSCIUSKO 21ST CENTURY FOUNDATION INC AKA K21 HEALTH FOUNDATION KOSC 5742695188 1101 PARK AVE WINONA LAKE IN 46590 RICH HADDAD PRESIDENT 5742695188 2023-05-09 1 RICH HADDAD 999009999 0 EMILIE M KNIERIEM CPA P01330194 3176334705 2023-05-09 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z X 75847769 X 231637 586504 586504 890389 890389 218527 218527 64090 1477010 64339020 1477010 154578 154578 0 3558645 3327008 0 226326 0 0 226326 103533 0 0 99948 27302 0 0 27302 19525 0 0 19525 269947 269947 0 0 1953 1268 0 685 214061 153121 0 32762 0 0 32762 7230 0 0 7230 3825 0 0 3825 172694 1316 0 170890 1079158 425652 0 588493 3818887 3860667 4898045 425652 0 4449160 -1339400 2901356 0 4938009 1368644 1368645 10748 10260 10260 6319390 6915768 6477548 27989927 26171276 36943666 8914763 5829440 5428417 2328270 1263697 1217694 1064573 1064573 14686114 21215986 23451052 1064979 158457 958062 906522 906522 252193 197086 197086 65286900 63679555 75847769 38866 3585 312179 270399 360022 169138 711067 443122 X 63060146 61759412 1515687 1477021 64575833 63236433 65286900 63679555 64575833 -1339400 0 63236433 0 63236433 SALES OF SECURITIES 64339020 62862010 1477010 1477010 1477010 40329 0 40329 0 40329 48000 0 0 0 48000 X 42 7629 7629 0 0 0 0 0 0 0 0 0 0 0 1 1 IN 1 0 0 0 0 1 WWW.K21FOUNDATION.ORG RICH HADDAD 5742695188 1101 PARK AVE WINONA LAKE IN 46590 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 RICHARD HADDAD 1101 PARK AVE WINONA LAKE IN 46590 PRESIDENT 40.00 219909 6417 0 LISA O'NEILL 1101 PARK AVE WINONA LAKE IN 46590 CHAIRMAN 1.00 0 0 0 BILL SMITH 1101 PARK AVE WINONA LAKE IN 46590 VICE CHAIRMAN 1.00 0 0 0 MAX MOCK 1101 PARK AVE WINONA LAKE IN 46590 TREASURER 1.00 0 0 0 JILL GROSS 1101 PARK AVE WINONA LAKE IN 46590 SECRETARY 1.00 0 0 0 BECKY ALLES 1101 PARK AVE WINONA LAKE IN 46590 DIRECTOR 1.00 0 0 0 JESSICA BRICKER 1101 PARK AVE WINONA LAKE IN 46590 DIRECTOR 1.00 0 0 0 TRICIA GALL 1101 PARK AVE WINONA LAKE IN 46590 DIRECTOR-TERM BEGAN 1.00 0 0 0 JOE GRAHAM 1101 PARK AVE WINONA LAKE IN 46590 DIRECTOR 1.00 0 0 0 ANDREW GROSSNICKLE 1101 PARK AVE WINONA LAKE IN 46590 DIRECTOR 1.00 0 0 0 JOELLA HAUSEMANN 1101 PARK AVE WINONA LAKE IN 46590 DIRECTOR 1.00 0 0 0 KELLY KAASE 1101 PARK AVE WINONA LAKE IN 46590 DIRECTOR 1.00 0 0 0 RICK KERLIN 1101 PARK AVE WINONA LAKE IN 46590 DIRECTOR 1.00 0 0 0 ANITA KISHAN 1101 PARK AVE WINONA LAKE IN 46590 DIRECTOR 1.00 0 0 0 CHAD LARSH 1101 PARK AVE WINONA LAKE IN 46590 DIRECTOR 1.00 0 0 0 SANDRA PARRA 1101 PARK AVE WINONA LAKE IN 46590 DIRECTOR 1.00 0 0 0 DR JASMINE SCHLITT 1101 PARK AVE WINONA LAKE IN 46590 DIRECTOR 1.00 0 0 0 SCOTT TUCKER 1101 PARK AVE WINONA LAKE IN 46590 DIRECTOR 1.00 0 0 0 STEVE GRILL 1101 PARK AVE WINONA LAKE IN 46590 DIRECTOR-TERM ENDED 1.00 0 0 0 JENNIFER STEWART 1101 PARK AVE WINONA LAKE IN 46590 MARKETING MANAGER 40.00 56929 1672 0 0 ROBINSON CONSTRUCTION 445 E 200 NORTH WARSAW IN 46582 CONSTRUCTION 285969 A&Z ENGINGEERING 1220 RUSTON PASS FORT WAYNE IN 46825 ENGINEERING 78623 MARQUETTE ASSOCIATES 180 N LASALLE SUITE 3500 CHICAGO IL 60601 INVESTMENT CONSULTING 69000 PHEND & BROWN PO BOX 150 MILFORD IN 46542 CONSTRUCTION 53000 0 0 0 79340725 532447 0 79873172 0 0 79873172 1198098 78675074 3933754 3933754 40329 40329 3893425 0 3893425 0 3893425 4449160 0 4449160 3893425 0 0 537887 624896 712716 1875499 4449160 0 0 0 3893425 555735 0 0 2431234 0 0 0 0 0 0 537887 1893347 624896 712716 555735 KOSCIUSKO 21ST CENTURY FOUNDATION I 1101 PARK AVE WINONA LAKE IN 46590 5742695188 SEE STATEMENTS 20 AND 21. SEE STATEMENTS 20 AND 21. SEE STATEMENTS 20 AND 21. CANCER CARE GRANTS 1101 PARK AVE WINONA LAKE IN 46590 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 140059 AGAITAS 1945 PHEASANT RIDGE DRIVE WARSAW IN 46580 NONE PC OPERATIONAL FUNDING 15000 AGAITAS 710 PARK AVE WINONA LAKE IN 46590 NONE PC OPERATING SUPPORT 2500 BAKER YOUTH CLUB 1401 E SMITH ST WARSAW IN 46580 NONE PC OPERATIONAL ASSISTANCE 50000 BAKER YOUTH CLUB 1400 E SMITH ST WARSAW IN 46580 NONE PC OPERATING SUPPORT 1500 BIG BROTHERS BIG SISTERS 1005 WEST RUDISILL BLVD FORT WAYNE IN 46807 NONE PC OPERATIONAL ASSISTANCE 5000 BOWEN CENTER 2621 E JEFFERSON ST WARSAW IN 46581 NONE PC COMMUNITY PARK SUPPORT 38460 BRIGHTPOINT 227 E WASHINGTON BLVD FORT WAYNE IN 46804 NONE PC COVERING KIDS & FAMILIES 20000 CANCER SERVICES OF NORTHEAST INDIANA 6316 MUTUAL DRIVE FORT WAYNE IN 46825 NONE PC DIRECT ASSISTANCE / CLIENT ADVOCACY 20000 CARDINAL SERVICES 504 N BAY ST WARSAW IN 46580 NONE PC FACILITY RENOVATION 338514 CITY OF WARSAW 2191 E FORT WAYNE ST WARSAW IN 46580 NONE GOV AUTOPULSE SUPPORT/PICKLEBALL COURTS/CARES EQUIPMENT 71272 COMBINED COMMUNITY SERVICES 1195 MARINERS DRIVE WARSAW IN 46582 NONE PC PROGRAM SUPPORT/STRATEGIC PLANNING 79225 COMBINED COMMUNITY SERVICES 1195 MARINERS DRIVE WARSAW IN 46582 NONE PC OPERATING SUPPORT 1000 FELLOWSHIP MISSIONS 1520 E WINONA AVE WARSAW IN 46580 NONE PC ADDICTION RECOVERY PROGRAM SUPPORT 100000 FELLOWSHIP MISSIONS 1520 EAST WINONA AVENUE WARSAW IN 46580 NONE PC OPERATING SUPPORT 1500 GRACE COLLEGE & SEMINARY 1 LANCER WAY WINONA LAKE IN 46590 NONE PC LILLY CENTER OPERATIONAL ASSISTANCE 10000 GRACE COLLEGE & SEMINARY 1 LANCER WAY WINONA LAKE IN 46590 NONE PC BIKES PROGRAM/LAKES STUDY 177971 HARVEST WITH A HEART PO BOX 425 MILFORD IN 46542 NONE PC FACILITY SUPPORT 7847 HEARTLINE PREGNANCY CENTER 1515 PROVIDENT DRIVE SUITE 180 WARSAW IN 46580 NONE PC PROGRAM FUNDING/FACILITY RENOVATION 42339 JOE'S KIDS 902 PROVIDENT DRIVE SUITE C WARSAW IN 46580 NONE PC COVID RELIEF SUPPORT 30000 JOE'S KIDS 902 PROVIDENT DRIVE SUITE C WARSAW IN 46580 NONE PC RENT SUBSIDY 41220 KCV CYCLING CLUB PO BOX 325 WINONA LAKE IN 46590 NONE PC TRAINING 2000 KOSCIUSKO CARES 1515 PROVIDENT DRIVE STE 240 WARSAW IN 46580 NONE PC PROGRAM SUPPORT 17000 KOSCIUSKO COMMUNITY YMCA 1305 MARINERS DR WARSAW IN 46582 NONE PC SCREENINGS 2300 KOSCIUSKO COMMUNITY YMCA 1305 MARINERS DRIVE WARSAW IN 46582 NONE PC TECHNOLOGY UPGRADE 13187 KOSCIUSKO COUNTY COMMUNITY FOUNDATION 102 EAST MARKET STREET WARSAW IN 46580 NONE PC GOOD SAMARITAN FUND/FUNDING PROGRAM 176000 KOSCIUSKO COUNTY COMMUNITY FOUNDATION 102 EAST MARKET STREET WARSAW IN 46580 NONE PC RILEY KIDS FUND 1000 KOSCIUSKO COUNTY COUNCIL ON AGING 800 N PARK AVE WARSAW IN 46580 NONE PC OPERATING SUPPORT 1000 KOSCIUSKO HEALTH SERVICES PAVILION 1515 PROVIDENT DRIVE WARSAW IN 46580 NONE PC COVID RELIEF SUPPORT 12500 KOSCIUSKO HEALTH SERVICES PAVILION 1515 PROVIDENT DRIVE WARSAW IN 46582 NONE PC FACILITY RENOVATION 24379 KOSCIUSKO HOME CARE & HOSPICE 1515 PROVIDENT DRIVE STE 250 WARSAW IN 46580 NONE PC OPERATIONAL ASSISTANCE 168179 KOSCIUSKO HOME CARE & HOSPICE 1515 PROVIDENT DRIVE STE 250 WARSAW IN 46580 NONE PC MEDICATION & DENTAL ASSISTANCE 247452 LAKE CITY BMX CLUB INC 750 E ARTHUR STREET WARSAW IN 46580 NONE PC TRACK IMPROVEMENT 34895 LITTLE LAMBS MINISTRY 1413 NORTH LONG DRIVE SYRACUSE IN 46567 NONE PC PLAYGROUND 15000 LIVE WELL KOSCIUSKO 8546 SOUTH 200 WEST CLAYPOOL IN 46510 NONE PC OPERATIONAL FUNDING 72479 LOST SPARROWS PO BOX 751 WINONA LAKE IN 46590 NONE PC CONFERENCE 20000 MAD ANTHONY'S CHILDREN'S HOPE HOUSE 7922 WEST JEFFERSON BLVD FORT WAYNE IN 46804 NONE PC OPERATIONAL ASSISTANCE 10000 MCMILLEN CENTER 600 JIM KELLEY BLVD FORT WAYNE IN 46816 NONE PC HEALTH EDUCATION PROGRAMS 5000 MOM OF AN ADDICT INC 10214 CHESTNUT PLAZA DR FORT WAYNE IN 46814 NONE PC PROGRAM SUPPORT 1984 NORTHERN INDIANA HISPANIC HEALTH COALITION 444 NORTH NAPPANEE STREET ELKHART IN 46514 NONE PC HEALTH SCREENINGS/OPERATIONAL FUNDING 20000 OTHER GRANTS LESS THAN 1000 1101 PARK AVE WINONA LAKE IN 46590 NONE PC OPERATING SUPPORT 5000 OUR LADY OF GUADALUPE CHURCH PO BOX 1136 WARSAW IN 46580 NONE PC OPERATING SUPPORT 1000 PLEASANT VIEW BIBLE CHURCH 2782 W 200 N WARSAW IN 46580 NONE PC PLAYGROUND 55047 RONALD MCDONALD HOUSE CHARITIES 11109 PARKVIEW PLAZA DR FORT WAYNE IN 46845 NONE PC MOBILE CLINIC AND OPERATING SUPPORT 5000 ROSE GARDEN RECOVERY COMMUNITY 72876 CR 29 SYRACUSE IN 46567 NONE PC OPERATING SUPPORT 1000 RYANS CASE FOR SMILES 295 E SWEDESFORD RD 396 WAYNE IN 19087 NONE PC PROGRAM SUPPLIES 3000 SIDNEY JACKSON TOWNSHIP VOLUNTEER FIRE DEPARTMENT 103 E CENTER STREET SIDNEY IN 46562 NONE PC GENERATOR 9307 SUPER SHOT INC 1515 HOBSON ROAD FORT WAYNE IN 46805 NONE PC OPERATIONAL ASSISTANCE 5000 THE OCEAN CLEANUP NORTH PACIFIC FOUNDATION 100 WALL STREET 10TH FLOOR NEW YORK IN 10005 NONE PC OCEAN CLEANUP 1000 THE WATERSHED FOUNDATION PO BOX 55 NORTH WEBSTER IN 46555 NONE PC OPERATING SUPPORT 1500 TOWN OF NORTH WEBSTER 144 SOUTH MAIN STREET NORTH WEBSTER IN 46555 NONE PC COMMUNITIES GRANT 1075 TOWN OF WINONA LAKE 1310 PARK AVENUE WINONA LAKE IN 46590 NONE PC ICE RINK PAVILION 1500000 TOWN OF WINONA LAKE 1590 PARK AVENUE WINONA LAKE IN 46590 NONE PC PICKLEBALL COURTS/AED EQUIPMENT & TRAINING 21280 TRITON SCHOOL CORPORATION 100 TRITON DRIVE BOURBON IN 46504 NONE PC FITNESS EQUIPMENT 35000 WAGON WHEEL THEATRE INC 2515 E CENTER ST WARSAW IN 46580 NONE PC OPERATING SUPPORT 1000 WARRIORS SWIM INC PO BOX 128 NORTH WEBSTER IN 46555 NONE PC EQUIPMENT 19000 WARSAW AQUATIC CLUB PO BOX 341 WINONA LAKE IN 46590 NONE PC OPERATING SUPPORT 1000 WARSAW COMMUNITY SCHOOLS 1 ADMINISTRATION DR WARSAW IN 46580 NONE PC NURSES FUND 10000 WARSAW COMMUNITY SCHOOLS 1 ADMINISTRATIION DRIVE WARSAW IN 46580 NONE PC FITNESS TRACKERS/PE EQUIPMENT 69073 WARSAW HEALTH EXPENSES 1101 PARK AVE WINONA LAKE IN 46590 NONE PC PARK DEVELOPMENT ALONG CENTER LAKE 78623 3860667 0 14 586504 14 890389 16 64090 01 154578 18 1477010 0 3172571 0 3172571 0 0 0 0 0 0 0 0 0 0 X X 1 THEIME FAMILY FOUNDATION 10925 BULLRUSH DR VENICE FL 34293 20000 X 2 MR AND MRS ED BURNWORTH 140 SEAVIEW CT UNITE 1001S MARCO ISLAND FL 34145 10000 X 3 MR AND MRS DOUGLAS SCHROCK 711 SOUTH STREET KEY WEST FL 33040 10000 X 4 MR AND MRS THOMAS HERALD 1300 S HARLESS DR B-7 SYRACUSE IN 46567 7500 X 5 BERTSCH FAMILY CHARITABLE FOUNDATION PO BOX 1494 WARSAW IN 46581 6000 X 6 MR AND MRS JEFF WELLS 11520 N LAKE VIEW SYRACUSE IN 46567 5400 X 7 LUTHERAN HEALTH NETWORK 7916 W JEFFERSON BLVD FORT WAYNE IN 46804 5000 X ACCOUNTING FEES 19525 0 0 19525 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 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 2022 THE CANCER CARE FUND PROVIDED FINANCIAL ASSISTANCE TO OVER 100 KOSCIUSKO COUNTY CANCER PATIENTS AND THEIR FAMILIES. THE FUND DISBURSED APPROXIMATELY $140,000 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. CORPORATE BONDS 5161173 4838488 FOREIGN BONDS 668267 589929 EQUITY SECURITIES 26171276 36943666 6915768 6477548 0 0 LAND IMPROVEMENTS 311605 179705 131900 131900 LEASEHOLD IMPROVEMENTS 969226 365124 604102 604102 BUILDING 1023544 718868 304676 304676 LAND 23895 0 23895 23895 REAL ESTATE INVESTMENT FUND FMV 1659916 3054245 HEDGE FUND FMV 3886111 3230176 GLOBAL MANAGED VOLATILITY FMV 2027289 3290350 US EQUITY INDEX PUTWRITE FUND LLC FMV 4477614 3928316 PRIVATE EQUITY FMV 1115833 1452344 INFRASTRUCTURE INVESTMENTS FMV 4500000 4654016 INTERNATIONAL ROLLOVER FUND FMV 3549223 3841605 LAND 34100 0 34100 34100 OFFICE & COMPUTER EQUIPMENT 150770 69068 81702 81702 BUILDING 880109 89389 790720 790720 NOTES RECEIVABLE HELD FOR GRANT MAKING 251002 185240 185240 RECEIVABLE - OTHER 1191 1212 1212 RECEIVABLE - TAX REFUND 0 10634 10634 FUNDRAISING EXPENSES 31622 0 0 31622 INSURANCE 10325 0 0 9837 MARKETING 95210 0 0 95210 MISCELLANEOUS EXPENSE 35537 1316 0 34221 OTHER INCOME 1060 1060 OTHER INCOME 153518 153518 DEFERRED TAX LIABILITY 360022 169138 INVESTMENT MGT FEES 269947 269947 0 0 FOREIGN INCOME TAXES 1268 1268 0 0 OTHER TAXES 685 0 0 685