2016-05-10T15:52:48-05:00 2015-12-31 351178661 Blue & Co LLC 500 N Meridian St Suite 200 Indianapolis IN 46204 990PF 2015-01-01 351187105 Kosciusko 21st Century Foundation Inc aka K21 Health Foundation KOSC 5742695188 2170 N Pointe Drive Warsaw IN 46582 RICH HADDAD PRESIDENT 5742695188 2016-05-05 1 Angela N Crawford P00418596 3176334705 2016-05-05 2015 2016-09-27 15:27:22Z X 69197070 X 250498 554339 554339 1050011 1050011 160829 160829 38942 2642580 45742308 2642580 2265 2265 0 4660522 4410024 0 173338 0 0 173338 74166 0 0 244701 25099 0 0 25099 480 0 0 480 26700 0 0 26700 211444 211444 0 0 16624 0 0 0 114079 109022 0 43953 0 0 43953 17417 0 0 17417 4572 0 0 4572 303942 12865 0 127975 1011814 333331 0 664235 3346455 3427569 4358269 333331 0 4091804 302253 4076693 0 1376152 865613 865613 7246 8473 8473 5178594 5922534 5883666 33991798 33820865 41331672 9704881 9401571 9221904 1893615 238646 1763992 1654969 1654969 5338895 5383543 6211061 88993 84602 9448 4391 4391 3598804 4015321 4015321 60969810 61077280 69197070 351 13762 652311 577036 105533 81198 758195 671996 X 59826489 59954698 385126 450586 60211615 60405284 60969810 61077280 60211615 302253 3444065 63957933 3552649 60405284 Sale of Securities P 45742308 43099728 2642580 2642580 2642580 0 3838345 67153038 0.057158 3352218 62610514 0.053541 3002834 57062361 0.052624 3182910 57452206 0.055401 3227837 54610094 0.059107 0.277831 0.055566 66164115 3676475 40767 3717242 4250293 X 40767 0 40767 0 40767 40000 40000 X 81 848 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 173338 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 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 VALERIE WARNER 2170 North Pointe Drive warsaw IN 46582 DIRECTOR 1.00 0 0 0 NONE 0 DJ Construction Co Inc 3414 Elkhart Rd Goshen IN 46526 General Contractor 283910 Niblock PO Box 211 Bristol IN 46507 Paving contractor 125000 ButtTimmons Construction 6635 East 950 North Syracuse IN 46567 General Contractor 123118 WJ Carey Construction PO Box 534 South Whitley IN 46787 General Contractor 81900 Heiman Construction Inc 1125 Executive Drive Warsaw IN 46580 general Contractor 73420 2 Forgiveness of current Loan mortgage interest due from Kosciusko Health Services Pavilion, Inc., a section 501(c(3) Organization. 149900 Forgiveness of current Loan due from Harvest with a Heart, Inc. a section 501(c)(3) Organization. 8589 158489 66797603 374087 0 67171690 0 0 67171690 1007575 66164115 3308206 3308206 40767 40767 3267439 0 3267439 0 3267439 4091804 158489 4250293 40767 4209526 3267439 0 0 87852 87852 4250293 0 0 0 3267439 982854 0 0 1070706 0 0 0 0 0 0 0 1070706 87852 982854 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. Cancer Care Grant Abby Daugherty PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3542 Cancer Care Grant Amanda Dickinson PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2615 Cancer Care Grant Amanda Sudlow PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2974 Cancer Care Grant Angela Ward PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3888 Cancer Care Grant Anna Accettura PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 200 Cancer Care Grant Anthony Gee PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 917 Cancer Care Grant Bill Robertson PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 75 Cancer Care Grant Bradley Trostle PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1475 Cancer Care Grant Brenda Bowers PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1500 Cancer Care Grant Brenda Roberts PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 525 Cancer Care Grant Bryan Foreman PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4000 Cancer Care Grant Catherine Hawkins PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 433 Cancer Care Grant Charles Fletcher PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 728 Cancer Care Grant Charles Gibson PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2500 Cancer Care Grant Chester Clampitt PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1698 Cancer Care Grant Cindy Bolin PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 267 Cancer Care Grant David Burgess PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2000 Cancer Care Grant Deanna Smith PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 400 Cancer Care Grant DeWayne Creamer PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3519 Cancer Care Grant Diana Bailey PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 47 Cancer Care Grant Diana Goans PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 25 Cancer Care Grant Dianna Baker PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1503 Cancer Care Grant Dianna Heisler PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 875 Cancer Care Grant Eldred Ehmen PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 782 Cancer Care Grant Elizabeth Malagon PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 129 Cancer Care Grant Eusebio Malagon PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 402 Cancer Care Grant Fred Hewitt PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1511 Cancer Care Grant Garin Voorheis PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1000 Cancer Care Grant Georgina Mitchell PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4933 Cancer Care Grant Henrietta Meyer PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1458 Cancer Care Grant Irene Smith PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1900 Cancer Care Grant Isaac Crow PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1500 Cancer Care Grant James Fiorucci PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 100 Cancer Care Grant Janet Hofer PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1000 Cancer Care Grant Jannel Eakright PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1487 Cancer Care Grant Jason Bodley PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 7262 Cancer Care Grant Jason Schmidt PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2838 Cancer Care Grant Jay Horn PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 200 Cancer Care Grant Jeff Beaverson PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2562 Cancer Care Grant Jeffery Beaverson PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 930 Cancer Care Grant Jeni Fisher PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3375 Cancer Care Grant Jeremy Blackburn PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 63 Cancer Care Grant Jesse Hurley PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 500 Cancer Care Grant Jett Roe PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3297 Cancer Care Grant Jewell Sausaman PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 963 Cancer Care Grant Johnny Isaac PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 302 Cancer Care Grant Joyce McCleese PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1518 Cancer Care Grant Judith Childers PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 500 Cancer Care Grant Judy Childers PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1000 Cancer Care Grant Julia Youst PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 486 Cancer Care Grant Karleen Richards PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 360 Cancer Care Grant Kathy McElroy PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1211 Cancer Care Grant Kathy Reynolds PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 100 Cancer Care Grant Kenneth Farmer PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1350 Cancer Care Grant Leo Richey PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 250 Cancer Care Grant Leslie Carnes PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1360 Cancer Care Grant Linda Fletcher PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 500 Cancer Care Grant Linda Novotny PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 50 Cancer Care Grant Mandy Dickinson PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 876 Cancer Care Grant Margarita Maldona PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 725 Cancer Care Grant Marilyn Braddock PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1517 Cancer Care Grant Marshal Crawford PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 223 Cancer Care Grant Martha Allen PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 296 Cancer Care Grant Mary Geisleman PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 400 Cancer Care Grant Mary Isaac PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 25 Cancer Care Grant Mary Joyner PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 252 Cancer Care Grant Mary Kern PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1000 Cancer Care Grant Mary Potts PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2500 Cancer Care Grant Mary Wadkins PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 457 Cancer Care Grant Melody May PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2000 Cancer Care Grant Michelle Baker PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1000 Cancer Care Grant Mike Williamson PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 310 Cancer Care Grant Mitchell Dulworth PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 585 Cancer Care Grant Naoma Foreman PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4498 Cancer Care Grant Nathan Dolbee PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 500 Cancer Care Grant Patricia Keim PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 4490 Cancer Care Grant Peggy Stamper PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 50 Cancer Care Grant Rhonda Phillips PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 100 Cancer Care Grant Rita Sabo PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 450 Cancer Care Grant Robert Bloom PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 179 Cancer Care Grant Roberto Cervantes PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2730 Cancer Care Grant Robin Evans PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 500 Cancer Care Grant Ronald Ashby PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 485 Cancer Care Grant Ronald Konkle PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 5500 Cancer Care Grant Ronald Miller PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 902 Cancer Care Grant Russell Bailey PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 229 Cancer Care Grant Ryan Owen PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 641 Cancer Care Grant Sandra Tuncil PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 394 Cancer Care Grant Shirley Owens PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 305 Cancer Care Grant Susan Gerrity PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1969 Cancer Care Grant Tammy Martin PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2200 Cancer Care Grant Teo Xique PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 2887 Cancer Care Grant Tim Frame PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1334 Cancer Care Grant Vicki Randall PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 423 Cancer Care Grant Vickie Tolson PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 161 Cancer Care Grant Walter Larue PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1600 Cancer Care Grant Willie Fields PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 1843 Cancer Care Grant Wilma Justice PO Box 1810 Warsaw IN 465811810 NONE I PROVIDE FINANCIAL ASSISTANCE DUE TO CANCER DIAGNOSIS 3761 UNCONDITIONAL GRANT Baker Youth Club 1401 E Smith St Warsaw IN 46580 NONE PC Summer Fitness Program 27000 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 15000 UNCONDITIONAL GRANT Cancer Services of Northeast Indiana 6316 Mutual Drive Fort Wayne IN 46825 NONE PC Direct Assistance / Client Advocacy 15000 UNCONDITIONAL GRANT Combined Community Services 1195 Mariners Dr Warsaw IN 46582 NONE PC Project Independence 6460 UNCONDITIONAL GRANT Erin's House for Grieving Children 5670 YMCA Park Drvie West Fort Wayne IN 46835 NONE PC Operational Assistance 10000 UNCONDITIONAL GRANT Heartline Pregnancy Center 1515 Provident Drive Warsaw IN 46580 NONE PC Mobile Unit Operations 45000 UNCONDITIONAL GRANT Joe's Kids 3540 Commerci Dr Warsaw IN 46580 NONE PC Operational Assistance 37500 UNCONDITIONAL GRANT Kosciusko County Community Foundation 102 East Market Street Warsaw IN 46580 NONE PC Good Samaritan Fund 137500 UNCONDITIONAL GRANT Kosciusko Home Care & Hospice 1515 Provident Drive Ste 250 Warsaw IN 46580 NONE PC Operational Assistance 299380 UNCONDITIONAL GRANT Mad Anthony's Children's Hope House 7922 West Jefferson Blvd Fort Wayne IN 46804 NONE PC Operational Assistance 15000 UNCONDITIONAL GRANT North Webster UM Church 7822 E Epworth Forest Rd North Webster IN 46555 NONE PC Health Ed Program 7000 UNCONDITIONAL GRANT Questa Foundation for Education 6502 Constitution Drive Fort Wayne IN 46804 NONE PC Scholars Program 100000 UNCONDITIONAL GRANT Rose Home PO Box 571 Syracuse IN 46567 NONE PC Operational Assistance 10000 UNCONDITIONAL GRANT Ryan's Place PO Box 73 Goshen IN 46527 NONE PC Operational Assistance 5000 CONDITIONAL GRANT American Diabetes Association 6415 Castleway West Dr Ste 114 Indianapolis IN 46250 NONE PC Scholarships for children attending diabetes camp 8225 CONDITIONAL GRANT American Legion Post 253 756 S SR 13 North Webster IN 46555 NONE PC Handicap Accessible Van 29889 CONDITIONAL GRANT Baker Youth Club 1401 E Smith St Warsaw IN 46580 NONE PC Facility Support 20000 CONDITIONAL GRANT Bowen Center 850 North Harrison St Warsaw IN 46580 NONE PC Enchanted Hills Food Pantry 81900 CONDITIONAL GRANT Cardinal Services 504 North Bay Dr Warsaw IN 46580 NONE PC Handicap Accessible Van 15000 CONDITIONAL GRANT City of Warsaw 102 S Buffalo St Warsaw IN 46580 NONE PC Market St Pathway Development 375000 CONDITIONAL GRANT City of Warsaw 102 S Buffalo St Warsaw IN 46580 NONE PC Rescue Dive Boat and Cardiac Monitors 67793 CONDITIONAL GRANT Crosswinds 4150 Illinois Rd Fort Wayne IN 46804 NONE PC In-home Counseling services 8945 CONDITIONAL GRANT Fellowship Missions PO Box 382 Winona Lake IN 46590 NONE PC Facility Renovations 21700 CONDITIONAL GRANT Grace College & Seminary 200 Seminary Drive Winona Lake IN 46590 NONE PC Funds for Kosciusko Lakes & Streams research study 107348 CONDITIONAL GRANT Grace Village 337 Grace Village Dr Winona Lake IN 46590 NONE PC Rehabilitation Equipment 13340 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 39592 CONDITIONAL GRANT Joe's Kids 3540 Commerce Dr Warsaw IN 46580 NONE PC Operating Assistance and equipment 18000 CONDITIONAL GRANT Kosciusko County YMCA 1305 Mariners Dr Warsaw IN 46582 NONE PC New Facility Development 400000 CONDITIONAL GRANT Kosciusko County Council on Aging 800 Park Ave Warsaw IN 46580 NONE PC Transportation Van 12300 CONDITIONAL GRANT Kosciusko County Shelter for Abuse PO Box 12 Warsaw IN 46581 NONE PC New Facility Development 304442 CONDITIONAL GRANT Kosciusko County 221 W Main St Warsaw IN 46580 NONE PC Dive Equipment and Drug Court Support 21044 CONDITIONAL GRANT Kosciusko Health Services Pavilion 1515 Provident Dr Warsaw IN 46580 NONE PC Phone System and HVAC Repair 48971 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 188878 CONDITIONAL GRANT Lake City BMX Club 5105 N Dovewood Trail Warsaw IN 46582 NONE PC Track Renovations 47461 CONDITIONAL GRANT Magical Meadows 3386 E 525 North Warsaw IN 46582 NONE PC Parking Lot Renovations 30000 CONDITIONAL GRANT Multi-Township EMS 34 E Armstrong Rd Leesburg IN 46538 NONE PC Ambulance Cot Replacements 227500 CONDITIONAL GRANT North Webster Community Center PO Box 379 North Webster IN 46555 NONE PC Roof Replacement 31097 CONDITIONAL GRANT North Webster Tippecanoe Township PO Box 292 North Webster IN 46555 NONE PC ATV Rescue Vehicle 13787 CONDITIONAL GRANT Northern Indiana Hispanic Health Coalition 323 Stocker Court Elkhart IN 46516 NONE PC Operational funding for bilingual advocate/health fairs 35000 CONDITIONAL GRANT REAL Services 720 E Winona Ave Warsaw IN 46580 NONE PC Health Ed Workshops 1500 CONDITIONAL GRANT Serenity House 2438 CR 50 Auburn IN 46706 NONE PC New Rehab Facility 100000 CONDITIONAL GRANT Silver Lake Fire Dept PO Box 64 Silver Lake IN 46982 NONE PC Equipment for Helipad 4278 CONDITIONAL GRANT Syracuse Wawasee Park Foundation 1013 North Long Dr Syracuse IN 46567 NONE PC Trails Systems Development 50000 CONDITIONAL GRANT Teen Parents Succeeding 604 S Poplar Dr Syracuse IN 46567 NONE PC Playground Renovation 19100 CONDITIONAL GRANT Tippecanoe Valley School Corp 8343 S SR 19 Akron IN 46910 NONE PC Fitness Equipment 14775 CONDITIONAL GRANT Town of Pierceton PO Box 496 Pierceton IN 46562 NONE PC Pathway Development 125000 CONDITIONAL GRANT Town of Winona Lake 1310 Park Ave Winona Lake IN 46590 NONE PC Pathway Development 8875 CONDITIONAL GRANT Triton School Corp 300 Triton Dr Bourbon IN 46504 NONE PC Fitness Equipment 40138 CONDITIONAL GRANT other grants under 1000 PO Box 1810 Warsaw IN 465811810 NONE PC K21 Board of Directors Directed Donation 994 2nd Mile Mission PO Box 733 Winona Lake IN 46590 NONE PC K21 Board of Directors Directed Donation 1000 American Diabetes Association 6415 Castleway West Dr Ste 114 Indianapolis IN 46250 NONE PC K21 Board of Directors Directed Donation 2000 BPO Elks Lodge #802 310 E Center St Warsaw IN 46580 NONE PC Support for the Underprivaleged 1100 Baker Youth Club 1401 E Smith St Warsaw IN 46580 NONE PC K21 Board of Directors Directed Donation 1000 Beaman Home PO Box 12 Warsaw IN 46581 NONE PC K21 Board of Directors Directed Donation 2000 Church of the Brethren 2475 E 100 North Warsaw IN 46582 NONE PC K21 Board of Directors Directed Donation 1000 First UM Church of Warsaw 179 S Indiana St Warsaw IN 46580 NONE PC Community Closet Support 5000 Grace College & Seminary 200 Seminary Drive Winona Lake IN 46590 NONE PC K21 Board of Directors Directed Donation and Smoking Cessation 2000 NorthStar Medical Equipment 1241 Ridge Creek Trail Ada MI 49301 NONE PC Automatic External Defibrillators and supplies 4075 Tippecanoe Valley Community Schools 8343 South State Road 19 Akron IN 16910 NONE PC K21 Board of Directors Directed Donation 1000 Wagon Wheel Theater PO Box 804 Warsaw IN 46581 NONE PC K21 Board of Directors Directed Donation 1000 Warsaw Little League PO Box 153 Warsaw IN 46581 NONE PC K21 Board of Directors Directed Donation 1000 Other grants under 1000 PO box 1810 Warsaw IN 465811810 NONE PC K21 Board of Directors Directed Donation 5500 3427569 0 14 554339 14 1050011 16 38942 14 2265 18 2642580 0 4288137 0 4288137 0 0 0 0 0 0 0 0 0 0 X X 1 Donette Smock 5867 E Island Ave Syracuse IN 46567 30100 X 2 American Legion Post 253 PO Box 131 North Webster IN 46555 6400 X 3 Kosciusko Community Hospital 2101 E Dubois Drive Warsaw IN 46580 5500 X 4 Donald Gunden 64874 Orchard Drive Goshen IN 46526 5000 X 5 Douglas Schrock 631 E Northshore Dr Syracuse IN 46567 5000 X ACCOUNTING FEES 26700 0 0 26700 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 DOWNLOADED OR PRINTED FROM THE ORGANIZATION'S WEBSITE 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. ORIGINAL APPLICATION AND SUPPORTING DOCUMENTATION SHOULD BE SUBMITTED. TYPEWRITTEN APPLICATIONS ARE PREFERRED, HOWEVER, LEGIBLE HANDWRITTEN APPLICATIONS IN BLUE/BLACK INK ARE ACCEPTABLE. 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 2013 THE CANCER CARE FUND PROVIDED FINANCIAL ASSISTANCE TO MORE THAN 100 KOSCIUSKO COUNTY CANCER PATIENTS AND THEIR FAMILIES. THE FUND DISBURSED NEARLY $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 9035604 8866867 Foreign Bonds 365967 355037 EQUITY SECURITIES 33820865 41331672 5922534 5883666 0 0 LAND 23895 0 23895 23895 Land Improvements 291412 4857 286555 286555 Leasehold Improvements 554764 10542 544222 544222 Building 1023544 223247 800297 800297 REAL ESTATE INVESTMENT FUND FMV 2139142 2780646 Hedge FUND FMV 3244401 3430415 OFFICE & COMPUTER EQUIPMENT 87393 84602 2791 2791 Construction in Progress 1600 0 1600 1600 Legal Fees 480 0 0 480 Notes Receivable Held for grant making 3598650 4007053 4007053 RECEIVABLE - OTHER 154 8268 8268 Unrealized Gain on Investments 3552649 KHSP Mortgage Interest Forgiveness 149900 0 0 0 Harvest Loan Forgiveness 8589 0 0 0 Fundraising Expenses 51856 0 0 51856 INSURANCE 6948 0 0 6900 MARKETING 36173 0 0 36173 MISCELLANEOUS EXPENSE 31771 0 0 33046 Provident Expenses 12865 12865 0 0 Expired Grants 5840 0 0 0 Other Income 2265 2265 2015 Book Value and Market Value Change between years 3444065 Deferred Tax Liability 105533 81198 INVESTMENT MGT FEES 211444 211444 0 0 EXCISE TAXES 16624 0 0 0