2017-04-27T14:11:10-05:00 2016-12-31 351178661 Blue & Co LLC 500 N Meridian St Suite 200 Indianapolis IN 46204 990PF 2016-01-01 351187105 Kosciusko 21st Century Foundation Inc aka K21 Health Foundation KOSC 5742695188 2170 N Pointe Drive Warsaw IN 46582 RICH HADDAD PRESIDENT 5742695188 2017-04-27 1 Amber Kocher CPA P00418596 3176334705 2017-04-27 38.86.68.133 2017-04-27 14:11:08 ED P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 CB73872C89F6C9C373A48B74A8C019EAB5F72C00 2016 2021-01-29 14:40:06Z X 70319088 X 521390 632437 632437 846745 846745 148458 148458 25712 2198994 48621497 2198994 2959 2959 0 4350983 3829593 0 180972 0 0 180972 74620 0 0 77423 25092 0 0 25092 17000 0 0 17000 220951 220951 0 0 43666 0 0 0 111403 109022 0 43654 0 0 43654 20017 0 0 20017 3801 0 0 3801 1056533 13724 0 115379 1797709 343697 0 483338 2040169 2331359 3837878 343697 0 2814697 513105 3485896 0 865613 989203 989203 8473 8668 8668 5922534 5871192 5772281 33820865 31647424 39968754 9401571 9453825 9241735 1893615 347668 1654969 1545947 1545947 5383543 8657118 9658390 361446 62717 4391 298729 298729 4015321 2835381 2835381 61077280 61307487 70319088 13762 577036 298983 81198 90116 671996 389099 X 59954698 60369514 450586 548874 60405284 60918388 61077280 61307487 60405284 513105 891810 61810199 891811 60918388 Sale of Securities P 48621497 46422503 2198994 2198994 2198994 0 4209526 66164115 0.063622 3838345 67153038 0.057158 3352218 62610514 0.053541 3002834 57062361 0.052624 3182910 57452206 0.055401 0.282346 0.056469 64963804 3668441 34859 3703300 3729186 X 34859 0 34859 0 34859 40800 40800 X 5941 5941 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 2170 N Pointe Drive WARSAW IN 46582 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 RICHARD HADDAD 2170 North Pointe Drive Warsaw IN 46582 PRESIDENT 40.00 180972 5279 0 James TINKEY 2170 North Pointe Drive Warsaw IN 46582 Chairman 1.00 0 0 0 Scott Tucker 2170 North Pointe Drive warsaw IN 46582 Vice Chairman 1.00 0 0 0 Dana Krull 2170 North Pointe Drive warsaw IN 46582 Treasurer 1.00 0 0 0 Shari Boyle 2170 North Pointe Drive warsaw IN 46582 Secretary 1.00 0 0 0 Becky Alles 2170 North Pointe Drive warsaw IN 46582 diRECTOR 1.00 0 0 0 Karen Boling 2170 North Pointe Drive warsaw IN 46582 DiRECTOR 1.00 0 0 0 Dr David Dick 2170 North Pointe Drive warsaw IN 46582 diRECTOR 1.00 0 0 0 Rick Kerlin 2170 North Pointe Drive warsaw IN 46582 DIRECTOR 1.00 0 0 0 Steve Grill 2170 North Pointe Drive Warsaw IN 46582 DiRECTOR 1.00 0 0 0 Andrew Grossnickle 2170 North Pointe Drive warsaw IN 46582 DIRECTOR 1.00 0 0 0 Dr David Haines 2170 North Pointe Drive warsaw IN 46582 DIRECTOR 1.00 0 0 0 Joe Hawn 2170 North Pointe Drive warsaw IN 46582 DIRECTOR 1.00 0 0 0 Rosy Jansma 2170 North Pointe Drive warsaw IN 46582 DIRECTOR 1.00 0 0 0 Jennifer Lucht 2170 North Pointe Drive Warsaw IN 46582 DiRECTOR 1.00 0 0 0 Max Mock 2170 North Pointe Drive Warsaw IN 46582 DiRECTOR 1.00 0 0 0 Kevin Roberts 2170 North Pointe Drive warsaw IN 46582 DiRECTOR 1.00 0 0 0 Steve Ross 2170 North Pointe Drive warsaw IN 46582 DiRECTOR 1.00 0 0 0 NONE 0 WJ Carey Construction PO Box 534 South Whitley IN 46787 General Contractor 263385 Marquette Associates 180 N LaSalle Suite 3500 Chicago IL 60601 Investment Consulting 68000 0 Forgiveness of current Loan mortgage interest due from Kosciusko Health Services Pavilion, Inc., a section 501(c(3) Organization. 905900 Forgiveness of current Loan due from Harvest with a Heart, Inc. a section 501(c)(3) Organization. 8589 914489 65531560 421541 0 65953101 0 0 65953101 989297 64963804 3248190 3248190 34859 34859 3213331 0 3213331 0 3213331 2814697 914489 3729186 34859 3694327 3213331 0 0 87852 982854 1070706 3729186 0 0 0 3213331 515855 0 0 1586561 0 0 0 0 0 0 0 1586561 87852 982854 515855 KOSCIUSKO 21ST CENTURY FOUNDATION I 2170 North Pointe Drive Warsaw IN 46582 5742695188 SEE STATEMENTS 20 AND 21. SEE STATEMENTS 20 AND 21. SEE STATEMENTS 20 AND 21. DIRECT GRANT American Diabetes Association 6415 Castleway West Dr Ste 114 Indianapolis IN 46250 NONE PC K21 Board of Directors Directed Donation 1000 DIRECT GRANT Cardinal Services 504 North Bay Dr Warsaw IN 46580 NONE PC K21 Board of Directors Directed Donation 1000 DIRECT GRANT Chain 'O Lakes Chorus PO Box 303 Winona Lake IN 46590 NONE PC K21 Board of Directors Directed Donation 1000 DIRECT GRANT Fellowship Missions PO Box 382 Winona Lake IN 46590 NONE PC K21 Board of Directors Directed Donation 1000 DIRECT GRANT Grace College & Seminary 200 Seminary Drive Winona Lake IN 46590 NONE PC K21 Board of Directors Directed Donation 2000 DIRECT GRANT Gradway PO Box 174 Warsaw IN 46580 NONE PC K21 Board of Directors Directed Donation 1000 DIRECT GRANT Kosciusko County Shelter for Abuse Po Box 12 Warsaw IN 46581 NONE PC K21 Board of Directors Directed Donation 1000 DIRECT GRANT North Webster Day Care PO Box 316 North Webster IN 46555 NONE PC K21 Board of Directors Directed Donation 1000 DIRECT GRANT Riley Children's Foundation 30 South Meridian St Indianapolis IN 46204 NONE PC K21 Board of Directors Directed Donation 1000 DIRECT GRANT Tippecanoe Valley Community Schools 8343 South State Road 19 Akron IN 16910 NONE PC K21 Board of Directors Directed Donation 1000 DIRECT GRANT Wagon Wheel Theater PO Box 804 Warsaw IN 46581 NONE PC K21 Board of Directors Directed Donation 1000 DIRECT GRANT Northstar Medical 6308 E Fulton St Ada MI 49301 NONE PC AED Equipment 12211 DIRECT GRANT The Lutheran Foundation 3024 Fairfield Ave Fort Wayne IN 46807 NONE PC Addiction Program and Project Funding 50000 DIRECT GRANT Town of Winona Lake 1310 Park Ave Winona Lake IN 46590 NONE PC Tennis Courts at Park - Grill Memorial 89339 DIRECT GRANTS Other grants under 1000 PO box 1810 Warsaw IN 465811810 NONE PC K21 Board of Directors Directed Donation 5500 Cancer Care Grant Amanda Sudlow PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1104 Cancer Care Grant Amos England PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1416 Cancer Care Grant Angela Ward PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4924 Cancer Care Grant Anthony Gee PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 6298 Cancer Care Grant Bernadene Boggs PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4228 Cancer Care Grant Dallas Baugher PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1600 Cancer Care Grant Donald Caverley PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3192 Cancer Care Grant Dorothy Hash PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1180 Cancer Care Grant Fred Hewitt PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1055 Cancer Care Grant Garin Voorheis PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4000 Cancer Care Grant Isaac Crow PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 6000 Cancer Care Grant Jason Bodley PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2274 Cancer Care Grant Jesse Hurley PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3308 Cancer Care Grant Jett Roe PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4200 Cancer Care Grant Judy Roberts PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2500 Cancer Care Grant Karen Stephenson PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2145 Cancer Care Grant Larry Parker PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1284 Cancer Care Grant Leslie Carnes PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2785 Cancer Care Grant Lisa Seitz PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2500 Cancer Care Grant Marcelle Heady PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3500 Cancer Care Grant Maria Marquez PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2450 Cancer Care Grant Mary Potts PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1500 Cancer Care Grant Michael Dennin PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1000 Cancer Care Grant Mitchell Dulworth PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2667 Cancer Care Grant Naoma Foreman PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3200 Cancer Care Grant Patricia Keim PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4500 Cancer Care Grant Paul Tinkel PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1745 Cancer Care Grant Randall Graber PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1584 Cancer Care Grant Rhonda Allen PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 5587 Cancer Care Grant Rhonda Phillips PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2158 Cancer Care Grant Richard Kelly PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1900 Cancer Care Grant Rosa Ramos PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1402 Cancer Care Grant Sabrina Sherow PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1989 Cancer Care Grant Samantha Shepherd PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2000 Cancer Care Grant Shirley Owens PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1433 Cancer Care Grant Sondrea Hamilton PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1500 Cancer Care Grant Stephen Jones PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2500 Cancer Care Grant Tamara Drake PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 6000 Cancer Care Grant Teo Xique PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1103 Cancer Care Grant Vicki Randall PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4727 Cancer Care Grant Willie Fields PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2706 Cancer Care Grant Wilma Justice PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2352 Cancer Care Grant Other Grants less PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 19227 CONDITIONAL GRANT All Things New PO Box 367 Winona Lake IN 46590 NONE PC Facility Improvements 14189 CONDITIONAL GRANT American Diabetes Association 6415 Castleway West Dr Ste 114 Indianapolis IN 46250 NONE PC Scholarships for children attending diabetes camp 7050 CONDITIONAL GRANT Atwood Community Building PO Box 51 Atwood IN 46502 NONE PC AED 1674 CONDITIONAL GRANT Crosswinds 4150 Illinois Rd Fort Wayne IN 46804 NONE PC In-home Counseling services 35013 CONDITIONAL GRANT Fellowship Missions PO Box 382 Winona Lake IN 46590 NONE PC Facility Renovations 37000 CONDITIONAL GRANT Grace College & Seminary 200 Seminary Drive Winona Lake IN 46590 NONE PC Funds for Kosciusko Lakes & Streams research study 92652 CONDITIONAL GRANT Heartline Pregnancy Center 1515 Provident Dr Ste 180 Warsaw IN 46580 NONE PC B.A.B.E. Boutique, Clinical Supplies, Car Seats, STI Testing 37987 CONDITIONAL GRANT Kosciusko County YMCA 1305 Mariners Dr Warsaw IN 46582 NONE PC New Facility Development; LiveStrong Program 435000 CONDITIONAL GRANT Kosciusko County Council on Aging 800 Park Ave Warsaw IN 46580 NONE PC Transportation Van 26837 CONDITIONAL GRANT Kosciusko County Shelter for Abuse PO Box 12 Warsaw IN 46581 NONE PC New Facility Development 52056 CONDITIONAL GRANT Kosciusko Health Services Pavilion 1515 Provident Dr Warsaw IN 46580 NONE PC Phone System 11496 CONDITIONAL GRANT Kosciusko Home Care & Hospice 1515 Provident Drive Ste 250 Warsaw IN 46580 NONE PC Children's Oral Health, Medication and Dental, Medical Supplies 133449 CONDITIONAL GRANT Lake City BMX Club 5105 N Dovewood Trail Warsaw IN 46582 NONE PC Track Renovations 5100 CONDITIONAL GRANT Lakeland Christian Academy 1095 S 250 E Winona Lake IN 46590 NONE PC Tower Garden Systems 3512 CONDITIONAL GRANT Lifeline Youth and Family Services PO Box 80487 Fort Wayne IN 49898 NONE PC AED 1339 CONDITIONAL GRANT Little Lambs Ministry PO Box 176 Syracuse IN 46567 NONE PC Playground Renovation 10000 CONDITIONAL GRANT Northern Indiana Hispanic Health Coalition 323 Stocker Court Elkhart IN 46516 NONE PC Operational funding for bilingual advocate/health fairs 48750 CONDITIONAL GRANT Positive Resource Connection 525 Oxford Street Fort Wayne IN 46806 NONE PC Health Testing Supplies 1898 CONDITIONAL GRANT Questa Foundation 6502 Constitution Dr Fort Wayne IN 46804 NONE PC Health Scholars Program 70000 CONDITIONAL GRANT REAL Services 720 E Winona Ave Warsaw IN 46580 NONE PC Elderly programs 30000 CONDITIONAL GRANT Syracuse Wawasee Park Foundation 1013 North Long Dr Syracuse IN 46567 NONE PC Trails, Ice Rink, and equipment 44129 CONDITIONAL GRANT Town of Milford 121 S Main St Milford IN 46542 NONE PC Playground Renovation 40000 CONDITIONAL GRANT Town of Pierceton PO Box 496 Pierceton IN 46562 NONE PC Pathway Development 9363 CONDITIONAL GRANT Town of Winona Lake 1310 Park Ave Winona Lake IN 46590 NONE PC Pathway Development 113350 CONDITIONAL GRANT Warsaw Community Schools 1 Administration Dr Warsaw IN 46580 NONE PC Tower Garden Systems 18573 CONDITIONAL GRANT Young Tiger Football 1429 Durham Court Winona Lake IN 46590 NONE PC Equipment 7000 CONDITIONAL GRANT Other grants less than 1000 PO Box 1810 Warsaw IN 465811810 NONE PC To support stated purpose of grant 1126 UNCONDITIONAL GRANT Baker Youth Club 1401 E Smith St Warsaw IN 46580 NONE PC Summer Fitness Program 20000 UNCONDITIONAL GRANT Big Brothers Big Sisters 2349 Fairfield Avenue Fort Wayne IN 46807 NONE PC Stop Sexual Abuse Training 5000 UNCONDITIONAL GRANT Brightpoint 227 E Washington Blvd Fort Wayne IN 46804 NONE PC Operational Assistance 17500 UNCONDITIONAL GRANT Cancer Services of Northeast Indiana 6316 Mutual Drive Fort Wayne IN 46825 NONE PC Direct Assistance / Client Advocacy 15000 UNCONDITIONAL GRANT City of Warsaw 102 S Buffalo St Warsaw IN 46580 NONE PC DARE program 4000 UNCONDITIONAL GRANT Erin's House for Grieving Children 5670 YMCA Park Drvie West Fort Wayne IN 46835 NONE PC Operational Assistance 7500 UNCONDITIONAL GRANT Fellowship Missions PO Box 382 Winona Lake IN 46590 NONE PC Facility Repair 25000 UNCONDITIONAL GRANT Grace College 200 Seminary Drive Winona Lake IN 46590 NONE PC CLAS Operating Assistance; tobacco cessation program 49425 UNCONDITIONAL GRANT Heartline Pregnancy Center 1515 Provident Drive Warsaw IN 46580 NONE PC Mobile Unit Operations 46000 UNCONDITIONAL GRANT Joe's Kids 3540 Commerci Dr Warsaw IN 46580 NONE PC Operational Assistance 12500 UNCONDITIONAL GRANT Kosciusko County Community Foundation 102 East Market Street Warsaw IN 46580 NONE PC Good Samaritan Fund 156250 UNCONDITIONAL GRANT Kosciusko County Shelter for Abuse PO Box 12 Warsaw IN 46581 NONE PC Operating Transition Assistance 30000 UNCONDITIONAL GRANT Kosciusko Home Care & Hospice 1515 Provident Drive Ste 250 Warsaw IN 46580 NONE PC Operational Assistance 329868 UNCONDITIONAL GRANT Mad Anthony's Children's Hope House 7922 West Jefferson Blvd Fort Wayne IN 46804 NONE PC Operational Assistance 15000 UNCONDITIONAL GRANT Ryan's Place PO Box 73 Goshen IN 46527 NONE PC Operational Assistance 6000 2331359 0 14 632437 14 846745 16 25712 14 2959 18 2198994 0 3706847 0 3706847 0 0 0 0 0 0 0 0 0 0 X X 1 Multi-Township EMS Corporation 34 E Armstrong Rd leesburg IN 46538 250000 X 2 Donette Smock 5867 E Island Ave Syracuse IN 46567 35300 X 3 Douglas Schrock 631 E Northshore Dr Syracuse IN 46567 10575 X 4 Brian Hull 7796 E Vawter Park Rd Syracuse IN 46567 10570 X 5 Zimmer Biomet 345 E Main St warsaw IN 46580 10000 X 6 Bertsch Family Charitable Foundation PO Box 1494 warsaw IN 46581 6000 X 7 Kosciusko Community Hospital 2101 E Dubois Drive Warsaw IN 46580 5500 X 8 Donald Gunden 64874 Orchard Drive Goshen IN 46526 5000 X ACCOUNTING FEES 17000 0 0 17000 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 LIFESTYLES. 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 PRIRORITES 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 NEARLY ALL SITUATIONS, FINANCIAL ASSISTANCE IS PAID DIRECTLY TO A VENDOR ON BEHALF OF THE CLIENTS. IN 2016 THE CANCER CARE FUND PROVIDED FINANCIAL ASSISTANCE TO APPROXIMATELY 100 KOSCIUSKO COUNTY CANCER PATIENTS AND THEIR FAMILIES. THE FUND DISBURSED OVER $100,000 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 COOPER AT (574) 372-3500 OR LAURA@THEBEAMANHOME.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. CORPORATE BONDS 8944452 8748184 Foreign Bonds 509373 493551 EQUITY SECURITIES 31647424 39968754 5871192 5772281 0 0 LAND 23895 0 23895 23895 Land Improvements 291412 4857 286555 286555 Leasehold Improvements 554764 10542 544222 544222 Building 1023544 332269 691275 691275 REAL ESTATE INVESTMENT FUND FMV 2164563 2898826 Hedge FUND FMV 3391693 3284184 Global Managed Volatility FMV 3100862 3475380 OFFICE & COMPUTER EQUIPMENT 68643 62717 5926 5926 Construction in Progress 292803 0 292803 292803 Notes Receivable Held for grant making 4007053 2829100 2829100 RECEIVABLE - OTHER 8268 340 340 Excise Tax Asset - Overpayment 0 5941 5941 2016 Book Value and Market Value Change between years 891811 KHSP Mortgage Interest Forgiveness 905900 0 0 0 Harvest Loan Forgiveness 8589 0 0 0 Fundraising Expenses 38379 0 0 38379 INSURANCE 7003 0 0 7148 MARKETING 37520 0 0 37520 MISCELLANEOUS EXPENSE 46006 13724 0 32332 Expired Grants 13136 0 0 0 Other Income 2959 2959 Unrealized Gain on Investments 891810 Deferred Tax Liability 81198 90116 INVESTMENT MGT FEES 220951 220951 0 0 EXCISE TAXES 43666 0 0 0