OMB No 1545-0047 Form 990 Return of Organization Exempt From Income Tax Under section 501 (c), 527, or 4947(aX1) of the Internal Revenue Code 2010 (except black lung benefit trust or private foundation) Open to Public Department of the Treasury Inspection Internal Revenue Service ► The organization may have to use a copy of this return to satisfy state reporting requirements A For the 2010 calendar year, or tax year beginning 11/01 , 2010 , and ending 10/31 , 2011 B Check if applicable D Employer Identification Number Address change The 200 Club of Somerset County 22-2588956 Name change P.O. Box 477 E Telephone number Somerville, NJ 08876 Initial return 908-722-6400 Terminated Amended return G Gross receipts $ 85,873. Application pending F Name and address of principal officer Robert Bukowczyk H(a) Is this a group return for affiliates" B Yes X No PO Box 179 Somerville, NJ 08876 H(b) Are all affiliates included' Yes No If 'No,' attach a list (see instructions) I Tax-exempt status FXI 501(c) ( ) ^ (Insert no ) 4947(a)(1) or 527
J Website : ► N/A H(c) Group exemption number ► K Form of organization X Corporation Trust 1-1 Association Other L Year of Formation 1972 M State of legal domicile NJ Part I Summary 1 Briefly describe the organization's mission or most significant activities Render financial assistance ------to widows,children & families_of policemen,_ firemen,-rescue workers or troopers who __ -dip- -or -are _ij ur.d -J-n- the_ line _Qf- duty -PxQYIc^ _co1 le e _sch o lar ah.ip .to _ch-i ldrea - - - -and/or _chi ldrs n .of parents , Saba ire actively .s ex ,Ti ng la -public _servic-e _fie lds__ _ _ - - 0 2 Check this box ► If the organization discontinued its operations or disposed of more than 25% of its net assets 3 Number of voting members of the governing body (Part VI, line 1a) 3 22 4 Number of independent voting members of the governing body (Part VI, line 1b) 4 22 5 Total number of individuals employed in calendar year 2010 (Part V, line 2a) 5 0 6 Total number of volunteers (estimate if necessary) 6 50 a 7a Total unrelated business revenue from Part VIII, colu n (C), ^-1CE 7a 0 . I VED b Net unrelated business taxable income from Form 99 T, 7b 0. JUL Prior Year Current Year U) 8 Contributions and grants (Part VIII, line Ili) A 8 0 2o l O 9 Program service revenue (Part VIII, line 2g) Lh 81,275. 79,300. 10 Investment Income (Part VIII, column (A), lines 3, 4, n dd 7 3G U ^ cc 11, 454. 6,573. 11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, + i 12 Total revenue - add lines 8 through 11 (must equal Part VIII, column (A), line 12) 92, 729. 85,873. 13 Grants and similar amounts paid (Part IX, column (A), lines 1-3) 37, 500. 32, 500. 14 Benefits paid to or for members (Part IX, column (A), line 4) 15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) F e 0% 16a Professional fundraising fees (Part IX, column (A), line 11e) b Total fundraising expenses (Part IX, column (D), line 25) ► a I" 17 Other expenses (Part IX, column (A), lines 1 1a-11d, 1lf-24f) 37,234. 38, 335. 18 Total expenses Add lines 13-17 (must equal Part IX, column (A), line 25) 74,734. 70, 835. 19 Revenue less expenses Subtract line 18 from line 12 17, 995. 15,038. Beginning of Current Year End of Year i e 20 Total assets (Part X, line 16) 497, 262. 512, 300. a9 21 Total liabilities (Part X, line 26) 0. 0. z 22 Net assets or fund balances Subtract line 21 from line 20 497, 262. 512,300. Part II Si g nature k Under penalt ies of perjury, P;dare. l 1 aye e xamme n accomp ymg schedules and statements , and to the best of knowledge and belief , it i s true , correct, and complete Declaration of preI er (otovf^an offs ased on I inform preparer has any knowledge
Sign S+gh3(ure of officer Here ► nil i r ,JAA, Ty0e6f print name and title Printlrype preparer's name Preparer's s+ ur
Paid Peter Johnson Preparer Firm's name ► Gillen & Use Only Firm's address ► 182 W. High St . - P.O. Box Somerville, NJ 08876 May the IRS discuss this return with the preparer shown above? (see I BAA For Paperwork Reduction Act Notice , see the separate instructi Form 990 (2010) The 200 Club of Somerset Count y 22-2588956 Page 2 Part III Statement of Program Service Accomplishments Check if Schedule 0 contains a response to any question in this Part III n 1 Briefly describe the organization's mission See Schedule ------0
2 Did the organization undertake any significant program services during the year which were not listed on the prior Form 990 or 990-EZ7 F1 Yes XI No If 'Yes,' describe these new services on Schedule 0 3 Did the organization cease conducting , or make significant changes in how it conducts , any program services? Yes X] No If 'Yes,' describe these changes on Schedule 0. 4 Describe the exempt purpose achievements for each of the organization 's three largest program services by expenses Section 501 (c)(3) and 501 (c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue , if any, for each program service reported
4a (Code ) (Expenses $ 32, 500. including grants of $ 32, 500. ) (Revenue $ 38, 650. Provide college scholarships to children and/or children of parents,_ who are actively ------serving in_thepublic_service fields. ------
4b (Code ) (Expenses $ 23, 899. including grants of $ ) (Revenue $ 38, 650. Renders financial assistance to widows, children and families of policemen, firemen, ------rescue squad workers or state troopers, who die or, are injured in-the-line of-duty.------
4c (Code ) (Expenses $ including grants of )(Revenue
4d Other program services (Describe in Schedule 0 ) (Expenses $ including grants of $ ) (Revenue $ 4e Total program service expenses ► 56, 399. BAA TEEA0102L 10/06/10 Form 990 (2010) Form 990 (2010) The 200 Club of Somerset County 22-2588956 Page 3 Part IV Checklist of Req uired Schedules Yes No
1 Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If 'Yes,' complete Schedule A 1 X 2 Is the organization required to complete Schedule B, Schedule of Contributors? (see instructions) 2 X 3 Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If 'Yes,' complete Schedule C, Part 1 3 X
4 Section 501(cX3) organizations Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If 'Yes,' complete Schedule C, Part Il 4 X
5 Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19' If 'Yes,' complete Schedule C, Part 111 5
6 Did the organization maintain any donor advised funds or any similar funds or accounts where donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If 'Yes,' complete Schedule D, Part 1 6 X
7 Did the organization receive or hold a conservation easement, including easements to preserve open space, the environment, historic land areas or historic structures' If 'Yes,' complete Schedule D, Part ll 7 X 8 Did the organization maintain collections of works of art, historical treasures, or other similar assets? If 'Yes,' complete Schedule D, Part 111 8 X
9 Did the organization report an amount in Part X, line 21, serve as a custodian for amounts not listed in Part X, or provide credit counseling, debt management, credit repair, or debt negotiation services? If 'Yes,' complete Schedule D, Part IV 9 X
10 Did the organization, directly or through a related organization, hold assets in term, permanent, or quasi-endowments? I 'Yes,' complete Schedule D, Part V 10 X
11 If the organization's answer to any of the following questions is 'Yes', then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable a Did the organization report an amount for land, buildings and equipment in Part X, line 10' If 'Yes,' complete Schedule D, Part VI 11 a X b Did the organization report an amount for investments- other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16' If 'Yes,' complete Schedule D, Part VII 11b X c Did the organization report an amount for investments- program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16' If 'Yes,' complete Schedule D, Part VIII 11C X d Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 167 If 'Yes,' complete Schedule D, Part IX 11d X e Did the organization report an amount for other liabilities in Part X, line 25' If 'Yes,' complete Schedule D, Part X Ill e X f Did the organization's separate or consolidated financial statements for the tax year include a footnote that addresses the organization's liability for uncertain tax positions under FIN 48 (ASC 740)' If 'Yes,' complete Schedule D, Part X 11 t X
12a Did the organization obtain separate, independent audited financial statements for the tax year? If 'Yes,' complete Schedule D, Parts Xl, XII, and XIII 12a X b Was the organization included in consolidated, independent audited financial statements for the tax year? If 'Yes,' and if the organization answered 'No' to line 12a, then completing Schedule D, Parts Xl, Xll, and Xlll is optional 12b X 13 Is the organization a school described in section 170(b)(1)(A)(ii)' If 'Yes,' complete Schedule E 13 X 14a Did the organization maintain an office, employees, or agents outside of the United States? 14a X b Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, and program service activities outside the United States? If 'Yes,' complete Schedule F, Parts I and IV 14b X
15 Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the United States? If 'Yes,' complete Schedule F, Parts ll and IV 15 X
16 Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? If 'Yes,' complete Schedule F, Parts 111 and IV 16 X
17 Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e' If 'Yes,' complete Schedule G, Part I (see instructions) 17 X 18 Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines lc and 8a' If 'Yes,' complete Schedule G, Part ll 18 X 19 Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a' If 'Yes,' complete Schedule G, Part 111 19 X 20 aDid the organization operate one or more hospitals? If 'Yes,' complete Schedule H 20 X
b If 'Yes' to line 20a, did the organization attach its audited financial statements to this return? Note . Some Form 990 filers that operate one or more hospitals must attach audited financial statements (see instructions) 20b BAA TEEA0103L 12/21110 Form 990 (2010) Form 990 (2010) The 200 Club of Somerset Count y 22-2588956 Page 4 Part IV Checklist of Req uired Schedules continued Yes No 21 Did the organization report more than $5,000 of grants and other assistance to governments and organizations in the United States on Part IX, column (A), line 1 ? If 'Yes,' complete Schedule I, Parts I and ll 21 X
22 Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If 'Yes,' complete Schedule I, Parts I and 111 22 X
23 Did the organization answer 'Yes' to Part VII, Section A, line 3, 4, or 5 about compensation of the organization's current and former officers, directors, trustees, key employees, and highest compensated employees? If 'Yes,' complete Schedule J 23 X 24a Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, and that was issued after December 31, 2002-2 If ' Yes, ' answer lines 24b through 24d and complete Schedule K If 'No,'go to line 25 24a X b Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception? 24b c Did the organization maintain an escrow account other than a refunding escrow at any time during the year to defease any tax-exempt bonds? 24c d Did the organization act as an 'on behalf of' issuer for bonds outstanding at any time during the year? 24d
25a Section 501(cx3) and 501(cX4) organizations . Did the organization engage in an excess benefit transaction with a disqualified person during the year? If 'Yes,' complete Schedule L, Part l 25a X
b Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization's prior Forms 990 or 990-EZ7 If 'Yes,' complete Schedule L, Part I 25b X
26 Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization's tax year? If 'Yes,' complete Schedule L, Part ll 26 X 27 Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor, or a grant selection committee member, or to a person related to such an individual? If 'Yes,' complete Schedule L, Part 111 27 X
28 Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions) a A current or former officer, director, trustee, or key employee? If 'Yes,' complete Schedule L, Part IV 28a X b A family member of a current or former officer, director, trustee, or key employee? If 'Yes,' complete Schedule L, Part IV 28b X c An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If 'Yes,' complete Schedule L, Part IV 28c X 29 Did the organization receive more than $25,000 in non-cash contributions? If 'Yes,' complete Schedule M 29 X 30 Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If 'Yes,' complete Schedule M 30 X 31 Did the organization liquidate, terminate, or dissolve and cease operations? If 'Yes,' complete Schedule N, Part 1 31 X 32 Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If 'Yes,' complete Schedule N, Part ll 32 X 33 Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301 7701-2 and 301 7701-37 If 'Yes,' complete Schedule R, Part 1 33 X 34 Was the organization related to any tax-exempt or taxable entity? If 'Yes,' complete Schedule R, Parts ll, Ill, IV, and V, line 1 34 X 35 Is any related organization a controlled entity within the meaning of section 512(b)(13)7 35 X a Did the organization receive any payment from or engage in any transaction with a controlled entity w ith in the meaning of sec t ion 512 (b)( 13) 7 If 'Yes, ' comple te Schedule R, Part V, line 2 E Yes N o
36 Section 501(cx3) organizations . Did the organization make any transfers to an exempt non-charitable related organization? If 'Yes,' complete Schedule R, Part V, line 2 36 X
37 Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If 'Yes,' complete Schedule R, Part VI 37 X
38 Did the organization complete Schedule 0 and provide explanations in Schedule 0 for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule 0 38 X BAA Form 990 (2010)
TEEA0104L 12/21/10 Form 990 (2010) The 200 Club of Somerset Count y 22-2588956 Page 5 PartV Statements Regarding Other IRS Filings and Tax Compliance Check if Schedule 0 contains a response to any question in this Part V Yes No 1 a Enter the number reported in Box 3 of Form 1096 Enter -0- i f not applicable 1 a 0 b Enter the number of Forms W-2G included in line la Enter -0- if not applicable lb 0 c Did the organization comply with backup withholding rules for reportable payments to vendo rs and reportable gaming (gambling) winnings to prize winners? 1 c 2a Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax State- ments, filed for the calendar year ending with or within the year covered by this return 2a 0 b If at least one is reported on line 2a, did the organization file all required federal employment tax returns? 2b Note . If the sum of lines la and 2a is greater than 250, you may be required to a-file (see instructions) 3a Did the organization have unrelated business gross income of $1,000 or more during the year? 3a X b If 'Yes' has it filed a Form 990-T for this year? If 'No,' provide an explanation in Schedule 0 3b 4a At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)? 4a X b If 'Yes,' enter the name of the foreign country 1, See instructions for filing requirements for Form TD F 90-22 1, Report of Foreign Bank and Financial Accounts 5a Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? 5a X b Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction? 5b X c If 'Yes,' to line 5a or 5b, did the organization file Form 8886-T' 5c
6a Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible? 6a X b If 'Yes,' did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible? 6b 7 Organizations that may receive deductible contributions under section 170(c). a Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor7 7a X b If 'Yes,' did the organization notify the donor of the value of the goods or services provided? 7b c Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282' 7c X d If 'Yes,' indicate the number of Forms 8282 filed during the year 7d e Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract? 7e X f Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? 7f X g If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required? 7g h If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C' 7h
8 Sponsoring organizations maintaining donor advised funds and section 509(aX3) supporting organizations . Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year? 8 9 Sponsoring organizations maintaining donor advised funds. a Did the organization make any taxable distributions under section 4966' 9a b Did the organization make a distribution to a donor, donor advisor, or related person? 9b 10 Section 501(c)(7) organizations. Enter a Initiation fees and capital contributions included on Part VIII, line 12 10a b Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities 10b 11 Section 501(cx12) organizations. Enter a Gross income from members or shareholders I 11 ai b Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them) 11 b 12a Section 4947(aXl) non -exempt charitable trusts . Is the organization filing Form 990 in lieu of Form 10417 12a b If 'Yes,' enter the amount of tax-exempt interest received or accrued during the year I 12b 13 Section 501(cX29) qualified nonprofit health insurance issuers. a Is the organization licensed to issue qualified health plans in more than one state? 13a Note . See the instructions for additional information the organization must report on Schedule 0 b Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans 13b c Enter the amount of reserves on hand 13c 14a Did the organization receive any payments for indoor tanning services during the tax year'? X b If 'Yes,' has it filed a Form 720 to report these pavments7 If 'No,' provide an explanation in Schedule 0 BAA TEEA0105L 11/30/10 Form 990 (2010) Form 990 (2010) The 200 Club of Somerset County 22-2588956 Page 6 Part VI Governance, Management and Disclosure For each 'Yes' response to lines 2 through 7b below, and for a 'No' response to line 8a, 8b, or l0b below, describe the circumstances, processes, or changes in Schedule 0. See Instructions. Check if Schedule 0 contains a response to any question in this Part VI n Section A. Governing Body and Management Yes No 1 a Enter the number of voting members of the governing body at the end of the tax year 1 a 22 b Enter the number of voting members included in line la, above, who are independent lb 22 2 Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee or key employee' 2 X 3 Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? 3 X 4 Did the organization make any significant changes to its governing documents 4 X since the prior Form 990 was filed? 5 Did the organization become aware during the year of a significant diversion of the organization's assets? 5 X 6 Does the organization have members or stockholders? See Schedule 0 6 X 7a Does the organization have members, stockholders, or other persons who may elect one or more members of the governing body'? See Schedule 0 7a X b Are any decisions of the governing body subject to approval by members, stockholders, or other persons? See Sch 0 7b X 8 Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following a The governing body? 8a X b Each committee with authority to act on behalf of the governing body' 8b _X 9 Is there any officer, director or trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization's mailing address? If 'Yes,' provide the names and addresses in Schedule 0 9 X Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code ) Yes No 10a Does the organization have local chapters, branches, or affiliates? 10a X b If 'Yes,' does the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with those of the organization? 10b 11 a Has the organization provided a copy of this Form 990 to all members of its governing body before filing the form? 11a X b Describe in Schedule 0 the process, if any, used by the organization to review this Form 990 See Schedule 0 12a Does the organization have a written conflict of interest policy? If 'No,' go to line 13 12a X b Are officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? 12b c Does the organization regularly and consistently monitor and enforce compliance with the policy? If 'Yes,' describe in Schedule 0 how this is done 12c 13 Does the organization have a written whistleblower policy? 13 X 14 Does the organization have a written document retention and destruction policy? 14 X 15 Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision? a The organization's CEO, Executive Director, or top management official 15a X b Other officers of key employees of the organization 15b X If 'Yes' to line 15a or 15b, describe the process in Schedule 0 (See instructions ) 16a Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? 16a X b If 'Yes,' has the organization adopted a written policy or procedure requiring the organization to evaluate its participation in point venture arrangements under applicable federal tax law, and taken steps to safeguard the organization's exempt status with respect to such arrangements? 16b Section C. Disclosure 17 List the states with which a copy of this Form 990 is required to be filed NJ ► ------18 Section 6104 requires an organization to make its Forms 1023 (or 1024 if applicable), 990, and 990-T (501 (c)(3)s only) available for public inspection Indicate how you make these available Check all that apply Own website Another's website Upon request 19 Describe in Schedule 0 whether (and if so, how) the organization makes its governing documents, conflict of interest policy, and financial statements available to the public See Schedule 0 20 State the name, physical address, and telephone number of the person who possesses the books and records of the organization -The Treasurer P.O. Box 477, Somerville, 08876 908-722-6400 ------NJ-
BAA Form 990 (2010)
TEEAO106L 12/21110 Form 990 (2010) The 200 Club of Somerset Count y 22-2588956 Page 7 Part VII Compensation of Officers , Directors , Trustees , Key Employees , Highest Compensated Employees, and Independent Contractors Check if Schedule 0 contains a response to any question in this Part VII F1 Section A. Officers, Directors , Trustees , Key Employees, and Highest Compensated Employees 1 a Complete this table for all persons required to be listed Report compensation for the calendar year ending with or within the organization's tax year • List all of the organization' s current officers directors, trustees (whether individuals or organizations), regardless of amount of compensation Enter -0- in columns (D), (E), and (F) if no compensation was paid • List all of the organization' s current key employees, if any See instructions for definition of 'key employee • List the organization's five current highest compensated employees (other than an officer, director, trustee, or key employee) who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the organization and any related organizations • List all of the organization' s former officers, key employees, and highest compensated employees who received more than $100,000 of reportable compensation from the organization and any related organizations • List all of the organization 's former directors or trustees that received, in the capacity as a former director or trustee of the organization, more than $10,000 of reportable compensation from the organization and any related organizations List persons in the following order individual trustees or directors, institutional trustees, officers, key employees, highest compensated employees, and former such persons FX] this box if neither the organization nor any related organization compensated any current officer, director, or trustee (A) (B) (C) (D) (E) (F) Name and title Average Position (check all that apply) Reportable Reportable Estimated hours > > p 0 ;F -n compensation from compensation from amount of other per week is 3. o the organization related organizations compensation (describe < . 3 (W-2/1099 MISC) (W-2/1099- MISC) from the hours for E , .° t( organization related o a n and related organiza - dj ° organizations bons in Schedule 0) m (1) Robert Hunt ------Vice President 0 0. 0. 0. (2) Robert Buk_owc zyk_ _ _ _ _ President 0 0. 0. 0. (3) Vito Mistretta ------Vice President 0 0. 0. 0. (4) Michael Vernoia ------Treasurer 0 0. 0. 0. -(5) Morgan McLachlan- _ _ _ _ Secretary 0 0. 0. 0. (6) ------Paul-Bell Trustee 0 0. 0. 0. _(7) Jim Collins Trustee 0 0. 0. 0. _ (8) Willaim Cooper ______Trustee 0 0. 0. 0. (9) Lawrence Corsini ------Trustee 0 0. 0. 0. Robert Corcoran -(10)------Trustee 0 0. 0. 0. (11) Jason Dameo ------Trustee 0 0. 0. 0. (12) Rocgue Dameo ______Trustee 0 0. 0. 0. (13) Michael Jankoski ------Trustee 0 0. 0. 0. S1a) Peter Johnson Trustee 0 0. 0. 0. (15) James Kennedy _ - _ _ _ _ _ Trustee 0 0. 0. 0. (16) John Kitchen ------Trustee 0 0. 0. 0. _(1_7)_ Aaron Ku r t zman ______Trustee 0 0. 0. 0. BAA m Ao1o7L 12/21/10 Form 990 (2010) Form 999 (2010) The 200 Club of Somerset County 22-2588956 Page 8 Part VII Section A. Officers. Directors. Trustees. Kev EmDlovees . and Hiahest Compensated Emnlovees (cunt) (A) (B) (c) (D) (E) (F) Name and title Average Position (check all that apply) Reportable Reportable Estimated hours o _ compensation from compensation from amount of other per week - a N 3 0 o-` m the organization related organizations compensation (describe a < g (W-2/1099-MISC) (W-211099-MISC) from the hours for ma f0 3`D o " rn organization related o ^ and related organs - - a o organizations nations n 9 in SO)ch
(18) Ned Lici tra ------Trustee 0 0. 0. 0. (19) D avid Lapani------Trustee 0 0. 0. 0. (20) Kevin McCallen ------Trustee 0 0. 0. 0. (21) Thomas Rafferty ______Trustee 0 0. 0. 0. (22) David Prugh ______Trustee 0 0. 0. 0. (23) Patricia_Ryan ------Trustee 0 0. 0. 0. (24) Charles Saladin ------Trustee 0 0. 0. 0. (25) Michael Scancarella ------Trustee 0 0. 0. 0. (26) Kenneth Scherer ------Trustee 0 0. 0. 0. (27) Eric Wasser ------Trustee 0 0. 0. 0. (28) ------
(29)
1 b Sub-total 0. 0. 0. 0. c Total from continuation sheets to Part VII, Section A 111. 0. 0. 0. d Total (add lines 1 b and 1 c) 0. 0. 0. 2 Total number of individuals (including but not limited to those listed above) who received more than $100,000 in reportable compensation from the organization 0. 0 No 3 Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line la? If 'Yes,' complete Schedule J for such individual 3 X 4 For any individual listed on line 1 a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000' If 'Yes' complete Schedule J for such individual 4 X 5 Did any person listed on line la receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If 'Yes,' complete Schedule J for such person 5 X Section B. Independent Contractors 1 Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization (A) (B) (C) Name and business address Description of services Compensation
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization ► 0 BAA TEEA01o8L 12121n0 Form 990 (2010) Form 990 (2010) The 200 Club of Somerset Count y 22- 2588956 Page 9 Part VIII Statement of Revenue (A) B (D) Total revenue Rel ated or Unre llated Revenue exempt business excluded from tax function revenue under sections revenue 512, 513, or 514 1 a Federated campaigns la b Membership dues lb N Q c Fundraising events 1 c t d Related organizations 1 d y g e Government grants (contributions) 1 e Z V; W f All other contributions, gifts, grants, and n similar amounts not included above 80 i d g Noncash contributions included in Ins la-If. $ = °a h Total . Add lines la-If W Business Code W 2a Membership Dues & Assessments 624200 79,300. 79,300. ------b W ------u C
> ------W d ------e o f All other program service revenue Total. Add lines 2a-2f 79, 300. 3 Investment income (including dividends, interest and other similar amounts) 6, 573. 6,573. 4 Income from investment of tax-exempt bond proceeds 5 Royalties (i) Real (ii) Personal 6a Gross Rents b Less rental expenses c Rental income or (loss) _ d Net rental income or (lo ss) (i) Securities (n) Other 7a Gross amount from sales of assets other than inventory b Less cost or other basis and sales expenses c Gain or (loss) d Net gain or (loss) 8a Gross income from fundraising events (not including $ > of contributions reported on line 1c) Ix Ix See Part IV, line 18 a X b Less direct expenses b ° c Net income or (loss) from fundraising events 9a Gross income from gaming activities See Part IV, line 19 a b Less direct expenses b c Net income or (loss) from gaming activit ies 10a Gross sales of inventory, less returns and allowances a b Less cost of goods sold b c Net income or (loss) from sales of Inventory Miscellaneous Revenue Business Code 11a ------b ------c ------d All other revenue e Total. Add lines 1la-11d 10. 1 12 Total revenue . See instructions 0- 1 85, 873. 85, 873. 0. 0. BAA TEEA0109L tonino Form 990 (2010) Form 990'(20101 The 200 Club of Somerset Count y 22-2588956 Page 10 Part IX Statement of Functional Expenses Section 501(c)(3) and 501(c)(4) organizations must complete all columns All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D) B (C) D Do not include amounts reported on lines Total expenses Program service Management and Fundraising 6b, 7b, 8b, 9b, and 10b of Part V///. expenses general ex enses expenses 1 Grants and other assistance to governments and organizations in the U S See Part IV, line 21 2 Grants and other assistance to individuals in the U S See Part IV , line 22 32,500. 32,500. 3 Grants and other assistance to governments, organizations , and individuals outside the U S See Part IV, lines 15 and 16 4 Benefits paid to or for members 5 Compensation of current officers , directors, trustees, and key employees 0. 0. 0. 0. 6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958 (c)(3)(B) . . . . 7 Other salaries and wages 8 Pension plan contributions (include section 401(k) and section 403(b) employer contributions) 9 Other employee benefits 10 Payroll taxes 11 Fees for services (non-employees) a Management b Legal c Accounting d Lobbying e Professional fundraising services See Part IV, line 17 f Investment management fees g Other 12 Advertising and promotion 13 Office expenses 14 Information technology 15 Royalties 16 Occupancy 17 Travel 18 Payments of travel or entertainment expenses for any federal , state, or local public officials 19 Conferences , conventions , and meetings 18, 161. 18,161. 20 Interest 21 Payments to affiliates 22 Depreciation , depletion, and amortization 23 Insurance 24 Other expenses Itemize expenses not covered above (List miscellaneous expenses in line 24f If line 24f amount exceeds 10% of line 25, column (A) amount , list line 24f expenses on Schedule O ) a Office E enses 11 , 475. 5 ,738. 5,737. b Secretarial Expenses- - - _ _ _ 8,631 . 8,631. License c ------fee 50. 50. d ------Credit card/bank fees 18. 18. e ------f All other expenses 25 Total functional expenses Add lines 1 through 24f 70 , 835. 56, 399. 14,436. 0. 26 Joint costs. Check here ► if following SOP 98 -2 (ASC 958-720) Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation BAA Form 990 (2010)
TEEA0110L 12/21/10 Form 990 (2010) The 200 Club of Somerset County 22-2588956 Page 11 Part X Balance Sheet (A) (B) Beginning of year End of year 1 Cash - non-interest-bearing 1 2 Savings and temporary cash investments 497, 262. 2 512,300. 3 Pledges and grants receivable, net 3 4 Accounts receivable, net 4
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees Complete Part II of Schedule L 5 6 Receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary - - - - organizations (see instructions) 6 A s 7 Notes and loans receivable, net 7 E 8 Inventories for sale or use 8 T s 9 Prepaid expenses and deferred charges 9
10a Land, buildings, and equipment cost or other basis Complete Part VI of Schedule D 10a - - b Less accumulated depreciation 10b 10c 11 Investments - publicly traded securities 11 12 Investments - other securities See Part IV, line 11 12 13 Investments - program-related See Part IV, line 11 13 14 Intangible assets 14 15 Other assets See Part IV, line 11 15 16 Total assets Add lines 1 through 15 (must equal line 34) 497, 262. 16 512, 300. 17 Accounts payable and accrued expenses 17 18 Grants payable 18 19 Deferred revenue 19 20 Tax-exempt bond liabilities 20 B 21 Escrow or custodial account liability Complete Part IV of Schedule D 21 1 L 22 Payables to current and former officers, directors, trustees, key employees, T highest compensated employees, and disqualified persons Complete Part II i of Schedule L 22 E s 23 Secured mortgages and notes payable to unrelated third parties 23 24 Unsecured notes and loans payable to unrelated third parties 24 25 Other liabilities Complete Part X of Schedule D 25 26 Total liabilities . Add lines 17 through 25 0. 26 0. E Organizations that follow SFAS 117, check here and complete lines T 27 through 29 and lines 33 and 34. A 27 Unrestricted net assets 27 T 28 Temporarily restricted net assets 28 s 29 Permanently restricted net assets 29 R Organizations that do not follow SFAS 117, check here and complete u lines 30 through 34. 0 30 Capital stock or trust principal, or current funds 30 A 31 Paid-in or capital surplus, or land, building, or equipment fund 31 A 32 Retained earnings, endowment, accumulated income, or other funds 497, 262. 32 512, 300. 33 Total net assets or fund balances 497, 262. 33 512, 300. S E 34 Total liabilities and net assets/fund balances 497, 262. 34 512, 300. BAA Form 990 (2010)
TEEA0111L 12/21/10 Form 990 (2010) The 200 Club of Somerset Count y 22-2588956 Page 12 Part XI Reconciliation of Net Assets Check if Schedule 0 contains a response to any Question in this Part XI F-1
1 Total revenue (must equal Part VIII, column (A), line 12) 1 85,873. 2 Total expenses (must equal Part IX, column (A), line 25) 2 70,835. 3 Revenue less expenses Subtract line 2 from line 1 3 15,038. 4 Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) 4 497, 262. 5 Other changes in net assets or fund balances (explain in Schedule 0) 5 0.
6 Net assets or fund balances at end of year Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) 6 512,300. Part X11 Financial Statements and Reporting Check if Schedule 0 contains a response to any question in this Part XII Yes No 1 Accounting method used to prepare the Form 990 XN Cash Accrual [ Other
If the organization changed its method of accounting from a prior year or checked 'Other,' explain in Schedule 0 2a Were the organization's financial statements compiled or reviewed by an independent accountant? 2a X b Were the organization's financial statements audited by an independent accountant? 2b X
c If 'Yes' to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? 2c If the organization changed either its oversight process or selection process during the tax year, explain in Schedule 0
d If 'Yes' to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both LI Separate basis LI Consolidated basis F1 Both consolidated and separate basis _ 3a As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-1337 3a X
b If 'Yes,' did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule 0 and describe any steps taken to undergo such audits 3b BAA Form 990 (2010)
TEFA0112L 12/21/10 OMB No 1545-0047 SCHEDULE A Public Charity (Form 990 or 990-EZ) Status and Public Support 1 2010 Complete if the organization is a section 501(cX3) organization or a section 4947(aXl) nonexempt charitable trust. Open to Public Department of the Treasury Inspection Internal Revenue Service Attach to Form 990 or Form 990-EZ. ► See separate instructions. Name of the organization Employer identification number The 200 Club of Somerset County 22-2588956 Part I I Reason for Public Charity Status (All organizations must com plete this part.) See instructions. The organization is not a private foundation because it is (For lines 1 through 11, check only one box ) 1 A church, convention of churches or association of churches described in section 170(bx1XA)C1). 2 A school described in section 170(bX1XA)Ci). (Attach Schedule E ) 3 A hospital or a cooperative hospital service organization described in section 170(bx1XA)(iii). 4 A medical research organization operated in conjunction with a hospital described in section 170(bX1XA)Cii) Enter the hospital's name, city, and state ______5 [ An organization operated for the benefit of a college or university owned or operated by- a governmental unit described in section 170(bx1XA)(iv). (Complete Part II ) 6 A federal, state, or local government or governmental unit described in section 170(bX1XAXv). 7 An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(bX1XAXvi ). (Complete Part II ) 8 q A community trust described in section 170(bX1XAXvi). (Complete Part II ) 9 An organization that normally receives (1) more than 33-1/3% of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions - subject to certain exceptions, and (2) no more than 33-1/3%, of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 30, 1975 See section 509(aX2). (Complete Part III ) 10 An organization organized and operated exclusively to test for public safety See section 509(aX4). 11 An organization organized and operated exclusively for the benefit of, to perform the functions of, or carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2) See section 509(aX3). Check the box that describes the type of supporting organization and complete lines 11 e through 11 h a [Type I b [ ]Type II CF] Type III - Functionally integrated d [] Type III - Other e El By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2) I If the organization received a written determination from the IRS that is a Type I, Type II or Type III supporting organization, check this box 11 Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons? Yes No (1) A person who directly or indirectly controls, either alone or together with persons described in (it) and (ill) below, the governing body of the supported organization? 11g(i) (i) A family member of a person described in (l) above? 11gCi) (iii) A 35% controlled entity of a person described in (I) or (ii) above? 11 g (iii) Provide the following information about the supported organization(s)
(1) Name of supported (i) EIN (n) Type of organization (v) Is the (v) Did you notify (vi) Is the (vii) Amount of support organization (described on lines 1 9 organization in the organization in organization in above or IRC section column (i) listed in column (i) of column (i) (see instructions)) your governing your support's organized in the document? U S 7 Yes No Yes No Yes No
(A)
(B)
(C)
(D)
(E)
Total BAA For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Schedule A (Form 990 or 990-EZ) 2010
TEEA0401L 12/23/10 Schedule A (Form 990 or 990-EZ) 2010 The 200 Club of Somerset Count y 22-2588956 Page 2 Part II Support Schedule for Organizations Described in Sections 170(bx1XAXiv) and 170(bX1XAXvi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III If the organization fails to qualify under the tests listed below, please complete Part III ) Se ctio n A. Public Support Calendar year (or fiscal year beginning in) 1, (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total 1 Gifts, grants, contributions, and membership fees received (Do not include 'unusual grants 2 Tax revenues levied for the organization's benefit and either paid to it or expended on its behalf 3 The value of services or facilities furnished by a governmental unit to the organization without charge 4 Total . Add lines 1 through 3 5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)
6 Public support . Subtract line 5 from line 4 Section B. Total Support Calendar year (or fiscal year (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total beginning in) ► 7 Amounts from line 4
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources 9 Net income from unrelated business activities, whether or not the business is regularly carried on 10 Other income Do not include gain or loss from the sale of capital assets (Explain in Part IV )
11 Total sup Port. Add lines 7 through 10 12 Gross receipts from related activities, etc (see instructions) 12 1
13 First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501 (c)(3) n organization, check this box and stop here ► Section C. Computation of Public Suppo rt Percentage 14 Public support percentage for 2010 (line 6, column (f) divided by line 11, column (f)) 15 Public support percentage from 2009 Schedule A, Part II, line 14
16a 33-1 /3% support test - 2010. If the organization did not check the box on line 13, and the line 14 is 33-1/3% or more, check this box q and stop here . The organization qualifies as a publicly supported organization ► b 33-1 /3% support test - 2009. If the organization did not check a box on line 13 or 16a, and line 15 is 33-1/3% or more, check this box q and stop here . The organization qualifies as a publicly supported organization ►
17a 10%-facts-and-circumstances test - 2010 . If the organization did not check a box on line 13, 16a, or 16b, and line 14 is 10% or more, and if the organization meets the 'facts-and-circumstances' test, check this box and stop here . Explain in Part IV how q the organization meets the 'facts-and-circumstances' test The organization qualifies as a publicly supported organization ►
b 10%-facts-and -circumstances test - 2009. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line 15 is 10% or more, and if the organization meets the 'facts-and-circumstances' test, check this box and stop here . Explain in Part IV how the organization meets the 'facts-and-circumstances' test The organization qualifies as a publicly supported organization ► 18 Private foundation . If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see instructions ► BAA Schedule A (Form 990 or 990-EZ) 2010
TEEA0402L 12/23/10 Schedule A (Form 990 or 990-EZ) 2010 The 200 Club of Somerset Count y 22-2588956 Page 3 Part III Support Schedule for Organizations Described in Section 509(aX2) (Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II If the organization fails to qualify under the tests listed below, pl ease co mpl ete Part II ) Section A. Public Support Calendar year (or fiscal yr beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total 1 Gifts, grants, contributions and membership fees received (Do not include any 'unusual grants ') 79,250. 78,285. 79,353. 81,275. 79,300. 397, 463. 2 Gross receipts from admis- sions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose 0. 3 Gross receipts from activities that are not an unrelated trade or business under section 513 0. 4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf 0. 5 The value of services or facilities furnished by a governmental unit to the organization without charge 0. 6 Total. Add lines 1 through 5 79,250, 78,285. 79,353. 81,275. 79,300. 397, 463. 7a Amounts included on lines 1, 2, and 3 received from disqualified persons 0. 01 0. 0. 0. 0. b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or I% of the amount on line 13 for the year 0. 0. 0. 0. 0. 0. c Add lines 7a and 7b 0. 0. 0 . 0. 0. 0. 8 Public support (Subtract line 7c fromline6) 397,463. Section B. Total Su Calendar year (or fiscal yr beginning In) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total 9 Amounts from line 6 79,250. 78,285. 79,353. 81,275. 79,300. 397,463. 10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources 17,778. 15,319. 11,642. 11,454. 6,573. 62,766. b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975 0. c Add lines 10a and 10b 17,778. 15,319. 11,642. 11,454. 6,573. 62,766. 11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on 0. 12 Other income Do not include gain or loss from the sale of capital assets (Explain in Part IV ) 0. 13 Total support . (Add Ins 9, 10c, 11, and 12) 97,028. 93,604. 90,995. 1 92,729. 85,873. 460,229. 14 First five years . If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here ► n Section C . Computation of Public SuoDort Percentaae 15 Public support percentage for 2010 (line 8, column (f) divided by line 13, column (f)) 15 86.4 % 16 Public support percentage from 2009 Schedule A, Part III, line 15 16 84.4 % Sectio n D . C omputation of Investment Income Percentage 17 Investment income percentage for 2010 (line 10c, column (f) divided by line 13, column (f)) 17 13.6 0 18 Investment income percentage from 2009 Schedule A, Part III, line 17 18 15.6 % 19a 33-1 /3% support tests - 2010. If the organization did not check the box on line 14, and line 15 is more than 33-1/3%, and line 17 is not more than 33-1/3%, check this box and stop here . The organization qualifies as a publicly supported organization ► b 33-1/3% support tests - 2009. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33-1/3%, and line 18 is not more than 33-1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ► 20 Private foundation . If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions ► BAA TEEAD403L 12/29no Schedule A (Form 990 or 990-EZ) 2010 Schedule A (Form 990 or 990-EZ) 2010 The 200 Club of Somerset Count y 22-2588956 Page 4 Part IV Supplemental Information . Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b, and Part III, line 12. Also complete this part for any additional information. (See Instructions).
BAA Schedule A (Form 990 or 990-EZ) 2010
TEEA0404L 09/08/10 OMB No 1545-0047 SCHEDULEI Grants and Other Assistance to Organizations, (Form 990) Governments and Individuals in the United States 2 010 Complete if the organization answered 'Yes,' to Form 990, Part IV, lines 21 or 22. Open to Public Department of the Treasury Internal Revenue Service Attatch to Form 990. Inspection Name of the organization Employer identification number The 200 Club of Somerset County 22-2588956 Part I I General Information on Grants and Assista nce
Does the organization maintain records to substantiate the amount of the grants or assistance , the grantees' eligibility for the grants or assistance, and the selection criteria used to award the grants or assistance? Yes N No 2 Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States Part II Grants and Other Assistance to Governments and Organizations in the United States . Complete if the organization answered 'Yes' to Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Part II can be duplicated if additional space is needed ► n 1 (a) Name and address of organization (b) EIN (c) IRC section (d) Amount of cash grant (e) Amount of non-cash (I) Method of valuation (g) Description of (h) Purpose of grant or government if appl i cable assistance (book, FMV, appraisal, non-cash assistance or assistance other)
------
------
2 ------
3 ------
4 ------
5 ------
6 ------
-91
------
total number of section 501(c)(3) and government organizations 3 Enter total number of other organizations ► 0 BAA For Paperwork Reduction Act Notice, see the Instructions for Form 990 . TEEA3901L 10/29/10 Schedule I (Form 990) 2010 Schedule I (Form 990) 2010 The 200 Club of Somerset Count y 22-2588956 Page 2 Part III Grants and Other Assistance to Individuals in the United States . Complete if the organization answered 'Yes' to Form 990, Part IV, line 22. Part III can be duplicated if additional space is needed.
(a) Type of grant or assistance (b) Number of (c) Amount of (d) Amount of (e) Method of valuation (book, (0 Description of non cash assistance recipients cash grant non-cash assistance FMV, appraisal, other)
1 32,500.
2
3
4
5
6
7 Part IV I Supplemental Information . Complete this part to provide the information required in Part 1, line 2, and any other additional information.
BAA Schedule I (Form 990) 2010
TEEA3902L 10/29/10 OMB No 1545-0047 SCHEDULE 0 Supplemental Information to Form 990 or 990-EZ (Form 990 or 990-EZ) 2010 Complete to provide information for responses to specific questions on Form 990 or 990-EZ or to provide any additional information. Open to Public Department of the Treasury Interna l Reve nue Service 0- Attach to Form 990 or 990-EZ. Inspection Name of the organization Employer identification number Club of Somerset Count 22-2588956
_ _ -Form 990, Part III Line 1 - Organization Mission ______------
- _ Render-financial an ce to-widows children_& families of policemenL _firemen,
- _ _rescue-workersor troopers whodieor are inured in the line of duty Provide ______-
- - -college -scholarships to -children and/or children of oarents , who are active - - - - _ - -
- - -serving in_public service fields._ _ ------_ _ -Form 990. Part Vl, Line 6_ Explanation of Classes of Members or Shareholder - - - - _ - _ _ _ - _ _
The Organization has members. ------
_ _ Form 990, Part V1 , Line 7a - How Members or Shareholders Elect Governing Body ______
At the Organization's Annual Meeting, the membership elects candidates to the Board ------
of Trustees from a slate of candidates proposed by a nominating committee, or ------nominations from the floor. The actions of the Board are rattified by the Membership ------at the Annual Meeting. ------Form 990, Part VI , Line 7b - Decisions of Governing Body Approval by Members or Shareholders ------Actions of the Board are rattified at the Annual Meeting. ------Form 990, Part VI , Line 11 b - Form 990 Review Process ------No review was or will be conducted. ------Form 990 , Part Vl , Line 19 - Other Organization Documents Publicly Available ------Upon request ------
BAA For Paperwork Reduction Act Notice , see the Instructions for Form 990 or 990 -EZ TEEA4901L 10/26/10 Schedule 0 (Form 990 or 990-EZ) 2010 THE 200 CLUB OF SOMERSET COUNTY - P.O. Box 179, Somerville, NJ 08876 www SomersetCounty200Club org 1-908-526-2565
An organization of concerned citizens pledged to render necessary financial assistance to the families who are left with little or no support when a police officer, firefighter, rescue squad member, or state trooper is seriously injured or loses their life in the line of duty
Name of Applicant Home Phone
Home Address
Name of Business Business Phone
Home Address
Dale of Birth Primary E-mail Address
Note must be 21 years of age at time of application Proposed by
I would be willing to serve on the following committees as indicated q Executive q Financial q Membership q Projects
I Important Notice - Please read carefully I
200 Club bylaws preclude membership of applicants with more than 5 Motor Vehicle points and/or having been convicted of a driving under the influence of drugs or alcohol offense within the last ten years
Please initial here. acknowledging that the applicant has less than 5 Motor Vehicle points and has never been convicted of a driving under the influence of drugs or alcohol offense within the last ten years
I enclose my check for $200 00* and understand that my application must be approved by the Board of Trustees Date Signature of Applicant
by
Form Instructions: Please fill out the form completely Sign the form and attach a check made payable to The 200 Club of Somerset County" in the amount of $200 00 Mail the completed form to the address at the top of the form
'Tax Deductible as Charitable Contribution by IRS Regulation PROGRAM THE SOMERSET COUNTY 200 CLUB Website: WELCOME Robert Bukowczyk, President www.somersetcounty200ciub.org We are a non-profit group of residents and businesses in PLEDGE TO FLAG Robert Bukowczyk, President Somerset County with a deep concern for the welfare of over five thousand policemen, firefighters, rescue squad members and N.J. State Police who protect our families and our property, INVOCATION Reverend Thomas P. Ganley - Chaplin 24 hours a day, seven days a week, year after year.... LUNCHEON Our Club is one of more than ninety-two clubs in the nation and nineteen in New Jersey. Other clubs in New Jersey are Essex, Union, Morris, Middlesex, Ocean, Monmouth, Mercer, INTRODUCTIONS Robert Bukowczyk, President Hunterdon, Warren, Hudson, Sussex, Bergen, Cape May, Atlantic, Burlington and Camden County, SCHOLARSHIP Robert H. Hunt, Jr. OUR RECIPIENTS PURPOSE To render necessary financial assistance to the families who are left with little or no support when a police officer, firefighter, rescue VALOR AWARDS Chief Brian R. Fitzgerald squad member, or state trooper is seriously injured loses their life Presentations Police Chief in the line of duty. Collectively we can, and must, fulfill our Branchburg Township Police Dept. obligation to these fine people In thirty-eight years of existence, our 200 Club has helped the Deputy Chief Lawrence Roberts families of numerous public servants Deputy Chief WHY GET INVOLVED? Franklin Township Police Dept. Please take a moment to think what it would be like without our local police officers . without our firefighters ... without our rescue Chief Dennis Manning squad members .. and without our state troopers. Police Chief The question answers itself. Somerville Borough Police Dept. WHAT CAN WE DO? GUEST SPEAKER Colonel Rick Fuentes Join us Join us in assisting the families of these members who have given the last full measure in the line of duty, Join us in our Superintendent efforts to cooperate with the state, county and municipal bodies New Jersey State Police in their quest to prevent further casualties. Join us in expanding our organization to better aid these deserving public servants. BENEDICTION Reverend Thomas P. Ganley - Chaplin HOW McCarrick Care Center, Somerset, NJ CAN YOU JOIN? Please use the application form on the back of this program to become a member. The Two Hundred Club of Somerset County May 18, 2011 depends entirely on the public spirited, civic minded citizens to Bridgewater Manor make the program financially possible. Bridgewater, New Jersey SCHOLARSHIP BOARD OF TRUSTEES PAUL W. BELL NED LICITRA For the 22nd straight year, the 200 Club of Somerset County is proud to be able to JIM COLLINS DAVID LIPANI present the following students with a $2,500 00 scholarship each WILLIAM COOPER KEVIN McCALLEN LAWRENCE CORSINI VITO MISTRETTA Kyle F Brands - Warren Hills Regional High School ROBERT CORCORAN DAVID PRUGH New Jersey State Police (parent) JASON DAMEO THOMAS J. RAFFERTY ROCQUE D DAMEO PATRICIA RYAN MICHAEL JENKOSKI CHARLES E SALADIN, JR. Lauren A Brands - Warren Hills Regional High School PETER JOHNSON MICHAEL SCANCARELLA New Jersey State Police (parent) JAMES KENNEDY KENNETH SCHERER JOHN KITCHEN ERIC S. WASSER Amanda C. Curry - Hillsborough High School * AARON KURTZMAN Montgomery Township Police Department (parent) PAST PRESIDENTS
Kara Czarcinski - Immaculata High School OFFICERS PRESIDENT...... ROBERT BUKOWCZYK Bound Brook Police Department (parent) VICE PRESIDENT...... Bound Brook Fire Department (parent & applicant) ROBERT H. HUNT, JR. VICE PRESIDENT MEMBERSHIP...... VITO MISTRETTA TREASURER ...... Virginia Doherty - Mount Saint Mary Academy MICHAEL VERNOIA, JR. SECRETARY ...... Warren Township Rescue (applicant) MORGAN McLACHLAN RECORDING SECRETARY...... DENISE MARIA Scott C. Du Barry - Somerville High School MEMBERSHIP SECRETARY...... NANCY PARKER North Branch Fire Company (applicant) COMMITTEES ACTION SCHOLARSHIP Erin N Gallagher - Delaware Valley Regional High School Rocque D. Dameo - Chairperson Robert H Hunt, Jr - Chairperson New Jersey State Police (parent) Paul Bell Robert Kapp Robert Bukowczyk Morgan McLachlan Rebecca M Guilloud - Academy for Health and Medical Sciences John Kitchen Glenn Pantel Hillsborough Rescue Squad (applicant) Morgan McLachlan Bruce Van Arsdale Thomas Rafferty Michael Vernoia. Jr Eric Wasser Lauren K Keane - South Plainfield High School BY-LAWS Warren Township Police Department (parent) Glenn Pantel - Chairperson VALOR AWARDS Eric Wasser Paul Consiglio - Chairperson Paul Bell Jessica B Lubas - Manville High School FINANCE COMMITTEE Raymond Hughes, Jr Somerset County Prosecutor's Office (parent) Mike Vernoia, Jr - Chairperson James Kennedy Larry Corsini John Kitchen Robert Hunt, Jr Alex R McQuade - Phillipsburg High School Dan Livak Charles E Saladin, Jr New Jersey State Police (parent) Vito Mistretta MEMBERSHIP John Morris Emily Sellar - Manville High School Vito Mistretta - Chairperson Eric Wasser James Kennedy - Co-Chairperson Manville Fire Department (parent) VALOR LUNCHEON Kevin M McCallen Paul Consiglio - Chairperson Morgan McLachlan Paul Bell Barry J Van Horn - Somerville High School Michael Vernoio, Jr Raymond Hughes, Jr. Somerville Fire Department (parent) NOMINATING James Kennedy Peter Johnson - Chairperson John Kitchen These students have been selected to receive scholarships based not Robert Corcoran Vito Mistretta necessarily on financial need, but also on their academic records well as their service as Raymond Hughes, Jr John Morris to school and community The awarding of these scholarships will bring our total to Thomas Rafferty Eric Wasser $577,500 00 in scholarship moneys given to 258 individuals' Kenneth Scherer Bruce Van Arsdale 1. THE 200 CLUB STORY: MEMBERSHIP The story of the 200 Clubs began back in 1950 when Sybil Reid Prugh Charles Richard Shanahan Jules Tischler Detroit Patrolman Andreas Mellert was shot in the back as he Kathryn Reiner Gary Shiman Scott Tourville Craig Repmann Charles Shinkle Jr Rose Tozzi escorted a charge to a patrol car. He left a young widow, who Ronald Repmann William Shortridge Albert Trabilsy, Jr was shortly due to go to the hospital for her first child. As a John Rice James Shrager JohnTria Kenneth Rice Krzysztot Siek John Trombadore widow, she would receive $4,000 and a pension of $170 a month. Ken Rice Bruce Sigman Gary Trombino William Packer, who had helped other policemen's families, Robert Ring Douglas Sikora Raymond Tropiano decided to write to 100 of his friends urging them to donate to Fortunato Ritorto Frederick Sikora Thomas True Brooke Rodgers Matthew Sikora Paul Twords a fund for the policeman's wife Andreas Mellert had been Terry Roe Jeffrey Silverman William Tybor Jr killed November 17, 1950 His posthumous child, Kathleen, was Dale Roller LLoyd Silverman Kenneth Utter Alan Rollins Dean Simko Michael Vallano born New Year's Eve. By this time his widow, Esther, left the Robert Roman Kristen Simko Thomas Van Syckel hospital; Packer, Detroit News columnist Jack Carlisle and Police Raymond Romano Salvatore Simonetti, Jr Thomas Van Syckel Commissioner George Gail Rosen Meera Singh Bruce VanArsdale Boos presented her a bankbook with Jay Rosen Walter Sisolack Robert Vanderoef $7,800. Later, the 200 Club set up a scholarship fund of $1000 for Angelo Rossi Arthur Skaar, Jr Peter Ventrella Kathleen. David Rudnitsky Harry Smith Ann Vernoia Douglas Rue Marshall Smith Sarah Vernoia Other widows were helped, but Packer began to question John Rupprecht Maurice Smith Michael Vernoia Jr why a permanent club wasn't formed with a standing treasury, Euene Rurka Michael Sockolof Michael Vesuvio Arlyn Rus Douglas Sonier Richard Viviano rather than individual efforts each time a crisis arose. Such a Jerry Russo Lance Spacek Irwin Vogel club was incorporated in the summer of 1952 with dues of $200 ' Patricia Ryan Marcy Spacek Thomas Vollers a year earmarked solely for widows and dependents. The first Rosamund Rybski Frankie Spalding John Voorhees Anthony Sa Max Spann Timothy Walter membership list of 100 began to grow to 200, 250, and more Stacy Sackett Cheryl Spatz Todd Walters Now there are over 500 members. Jerry Sager Sheldon Spatz ' Eric Wasser Michael Sakele Paul Spitalen Jason Weaver Other clubs have sprung up across the nation Some are Gail Saladin Chengad Sridhar Jack Welch known by other names: 200 Clubs, Shield Clubs, Bluecoats, Charles Saladin Jr Anthony Stankovich Mark Wetter Backstoppers and the like; but all share the same common goal Corby Salek Mark Stanton Shane Wierks Susanne Sailer George Starr William Wilcox of providing benefits to widows and children of slain officers A Wanda Sailer Fred Slauder Richard Wilterth number of clubs give awards to officers who exhibit exemplary William Sailer Jr Mark Steckroat Robert Wittemann Jr Jane San Giacomo Alan Steiner Henry Wittman III action in the course of their duties and today the work of the 200 Mark San Giacomo Martha Steiner Barbara Wolf Club continues to expand Terri Sapp Frederic Sterntt Bert Wolf John Scancarella Samuel Stettler Steven Wolf hrforrrrotion obtained /trout tire Sorrrer .set Corrru>> 200 Club brochure in Michael Scancarella Todd Stires Richard Workman Leonard Scharftenberger Allan Stock Frederick Wright 1984 by Torrr Rafferty Eugene Schenkman Bryan Stock Matthew Wright Kenneth Scherer Toni Stock Jonathan Wurst Scott Scherer Frank Stoudt George Young 2. OUR SOMERSET COUNTY 200 CLUB: Mitchel Scher Arthur Stryker, Jr William Young William Schmal Gail Sullivan Frank Yurasko Our Somerset County 200 Club started in 1972 with a Chris Schmidt Gerald Sullivan Robert Yurek membership of 57, and has presently a membership of 725 Robert Schmidt John Sullivan Richard Yusem public-spirited citizens with a deep concern for the welfare of Peter Schoberl Sylvester Sullivan Teri Zamkotowicz John Schuler Thomas Sullivan III Stephen Zampelta public safety officers. The 5000 members of the Somerset Ronald Schwarz Thomas Sullivan Jr Robert Zarelli County Police and Fire Departments and Rescue Squads, and Michael Scotillo III Gregory Summers Jeffrey Zeikel S Christopher Scrudato Douglas Sutton Thomas Zielinski the N J. State Police, protect our families and property twenty- William Sedlazek Pawel Szady four hours a day, seven days a week. Thomas Seibert Edward Szczepanik ` Past President is out 19 in the Joseph Seickel Roy Taverner Our Somerset County 200 Club one of Clubs Carl Sells David Taylor State of New Jersey and one out of about 92 in the Nation. Dolores Selody Stanley Tchorz Leslie SelodySteckroat Armen Tergevorkian Robert Sena Ralph Terracciano Jr MEMBERSHIP 3. OUR PURPOSE: Richard Kulik Kevin Mannion John O'Sullivan Job Kunkel Mary Patricia Mannion Horst Oertel To render necessary financial assistance to those widows, ' Aaron Kurtzman Patrick Mannion Nancy Oertel children and families who are left with little or no support when Christopher LaBelle Ken Marchi Vincent Oliva Joseph Laterrera Jr Alan Margulies Vincenzo Oliviero a member of the Police Force or Fire Department, Rescue Gregory Lamparello Martin Marino G Kevin Olsen Squad or the State Police loses his or her life in the line of duty Michael Lamparello Robert Marino Kurt Ortmann Samuel Lamparello Darlene Marks Eric Ostrow It is the opinion of these concerned citizens that collectively Larissa Lapitzki Edward Marks John Pakenham Jr we can and must fulfill our obligation to these fine people. Nicholas Lapitzki Robert Martin Bernard Pane III Somerset County 200 Club has helped families of numerous Thomas LaPlaca Harvey Masseau Anthony Panko Ernest Lanni Cynthia Maurer Esq Glenn Pantel officers, by awarding scholarships to the children of our first John LaRue Brian Mayer Allan Papp responders. Joseph LaSpada Mel Mayer Owen Pardo Alfred Lattanzio Hugh McAleavy Catherine Parello Frank Laudino Kevin McCallen Raymond Parello 4. ANNUAL VALOR AWARD LUNCHEON: Richard Laudino William McCollum Earle Parker Frank Laudino Jr Robert McCray Paul Parker Jeffrey Leach Arthur McGinnis Judith Pasnik Members of the Police and Fire Departments, the Rescue Jeffrey Lee Paul McKenna Michael Pasnik Squads and the State Police are often involved in dangerous Gerard Legato Morgan McLachlan Michael Pasnik Christopher Lenzo Kevin McNamara Joseph Pastore and life threatening confrontations. During these times our Bruce Levinston William Meekings Edward Paszkowski uniformed protectors do not hesitate to protect the public Peter Lewis William Megill DDS Kelly Anne Paszkowski Mark Lichtenfeld Mark Melchione Karl Paulus again and again, certain individuals perform heroic acts far Ned Licitra David Mendez Bernard Payne above and beyond the call of duty. Frank Lieto Debra Mendez Jens Bang Pedersen At an Annual Awards Luncheon our Somerset County 200 John Liggett William Mennen IV James Pellicane Janet Linnus Guy Merola George Peppe, Jr Club will honor those men and women we all respect and John Lipani Tod Mershon George Peppe, Sr admire for their total disregard for their own safety This is our David Lipani DMD Joseph Metelski Meghan Peragine Daniel Livak Ernst Michel Robert Petix Sr way to say THANK YOU to these outstanding public servants. David Livingston Paul Miele David Petrone The Valor Award recipients are chosen in part on the Michael Lobrace Gunnblorg Mikalsen Gina Petrone recommendations of our public service advisors which include Jerry Lobrow Jonathan Mikula Joseph Pezuti II Daniel Locker Thomas Miller Richard Pieros the Somerset County Police and Fire Departments, Rescue Stephen Locker Tom Miller Donald Pierrot Squads and State Police Department Michael Lombardi Richard Millet James Pilewski Dennis Loniak Vito Mistretta John Pella These Clubs are organizations composed of public-spirited Philip Lopa Jr John Mitchell John Pittenger citizens which raise funds through dues, initiation fees, and Peter Lorillard David Monahan Jr Dawn Pogosaew Christopher Luca Ronald Montana Theodore Pomianek contributions to provide assistance to surviving members of Jonathan Luca James Moore Joseph Ponce public safety officers who die in the line of duty There are William Luca Randal Morin Joseph Poole III often no distinctions drawn between calamities; survivors of a Kurt Ludwig Gregory Morris Gregory Porcino Dean Lurker John Morris John Powers police officer hurt while directing traffic are provided the some Mark Lytwyn Anthony Moscogiuri John Proske benefits as the family of an officer gunned down by a Peter Lytwyn Donald Mundy David Prugh William MacKenzie Rehan Murad Esq Daniel Puntillo "Saturday night special" wielded by a nationally sought criminal. Mario Maggio Thomas Murray Michael Purdy Such financial assistance has eliminated the unfortunate Richard Mahler Donald Musso Alex Puskas spectacle of voluntary collections being made following an Rahul Mahna Lawrence Najarian Frederick Quick Matthew Hoddy Mahon Jamsheed Naomi Gene Quintien officer's death that often fall woefully short of meeting Lou Malenchek Mark Newman Susan Radom fundamental needs. Richard Mancino, DMD Dean Newton ' Thomas Rafferty Paul Mandel Howard Norgalis Robert Ransone III Vincent Mangione Richard Norris Scott Rappoport Louis Mangione Jr Anthony Novello Bill Raska Paul Mann Robert O'Connor Denise Raska Thomas Manna Terrence O'Connor Jim Redington Colman Mannion Brent O'Neill Thomas Regetz GUEST SPEAKER MEMBERSHIP Ron Delucia Elizabeth Fuerst Peter Honeymar George DeNardo Steven Fuerst Jeffrey Horn William Denson Richard Fullam David Houser Christopher Dente Daniel Fulop Guy Hoyt Jacob Deutsch Jonathan Gabriel Edward Hughes Cynthia Devos Anthony Gaglia Mark Hughes Eric Devos Lynda Gaglia Samuel Hughes Stephanie Devos Thomas Galeta Raymond Hughes II Vincent Di Lorenzo Paul Garrin Robert Hunt Jr James Dick Stephen Gattoni Gant Husenal Walter Dietz III Gino Gavazzi Rustem Husenaj Maria Donegan Paul Gaynor Sejdi Husenaj William Dougherty Patrick Gelardi John Hyland Alan Douglas Arthur Gelfand Karen Hyland Ana Isabel Douglas Wilma Gelfand Daniel lammatteo Charles Drastura Bonnye Geller Anthony lanniello William Dreier Ira Geller Louis Ippolito Jr Colonel Rick Fuentes Patrick Driscoll Phil Getchis Mitchell Jablons Superintendent of the New Jersey State Police Robert DuBois Toni Giacchetto Michael Jenkoski Michael Dugan Steven Ginsberg Matthew Jerkovich Russell Dunlop Sal Giordano, Jr Joseph Jerkovich III On Monday June 2, 2003, Colonel Joseph R Fuentes was Wendy Dwyer Nora Giunci Bart Johnson selected by Governor James McGreevey to become the 14th Manfred Dyck William Gleason Gerald Johnson Ralph Ekberg Sr Roger Glynn ' Peter Johnson Superintendent of the New Jersey State Police Victor Elgort Ronald Glynn Stephen Johnson Anne Emmet Stacey Glynn-Brady William Jones D M D Superintendent Fuentes enlisted in the State Police in January Timothy Eng Eric Gold Thomas Jubak Sr 1978, as a member of the 93A Class He has served the Division Randall Enterline Ted Goldberg Richard Juntilla Edward Eskew Robert Golden Jerome Kadesh of State Police throughout the state, including assignments as Clifford Evans Cynthia Goldenberg Paul Kaplan, DMD a general road duty Trooper in Central and Southern New Steven Faigenbaum David Goldenberg Robert Kapp Jersey, and an instructor at the Sea Girt Academy. He also Sebastiano Fada Michael Grasso Brian Karluk was a supervisor with the FBI/NJSP Joint Terrorism Task Force, Paul Failla Mark Green John Karpinski Matthew Fantel Evan Greenberg Victoria Kasserman Narcotics Units, and the Street Gang Unit. Prior to being George Ralph Farley Murray Greenberg William Kasserman named Acting Superintendent, he was assigned as the Chief George Robert Farley Bryan Greene Joseph Kavanaugh Jr of the Intelligence Bureau, overseeing nine units within the James Farley Richard Greene Linda Keady Bradford Fenton Robert Greenfield Thomas Keady Intelligence Section. Joseph Ferdinando Dennis Gronan Herbert Keech Antonio Ferreira Jeffrey Gropper Nicholas Kehayas The recipient of numerous awards, Superintendent Fuentes Natalie Ferreira Martin Grozinski Stephen Keller has been recognized by the U S. Justice Department, Drug Nelson Ferreira Thor Guastella John Kelly Enforcement Administration, and in 1993 was a co-recipient of John Ferne John Guastella Sr James Kennedy George Edward Filepp Ellen Guido Richard Kennedy the New Jersey State Police Trooper of the Year award. Francis Flanagan Richard Guido Brian Kern Roger Flanagan Jr Robert Haase William Keslowe Superintendent Fuentes earned a Bachelor of Science Dennis Fleck Michael Haleluk John Kikta degree from Kean College of New Jersey in 1977, a Master of Steven Fleischer Matthew Hand Bill King John Fleming William Hanlon Michael King Arts in Criminal Justice from John Jay College of Criminal Ryan Foley Louis Harding Sandy King Justice, New York In 1992, and a Doctorate of Philosophy in Timothy Foley Charles Harrison Stephen King Criminal Justice from City University of New York in 1998 In Edward Foley III Ernest Hausmann Kirsten King-Sockolof 2006, Colonel Fuentes was appointed General Chair of the Jeff Fontenelk Walter Hazard Timothy Kiniery Philip Fornaro Larry Helwig John Kitchen State and Provincial Division of the IACP Wayne Forrest Frederick Henry Dori Knauer Steven Fox George Hnidj Leonard Knauer Superintendent Fuentes resides in Bergen County with his wife, Salvatore Franchino J Carl Hockenbury Jane Kobuta Eileen. Bracha Frank Jett Hockenbury Christopher Koch David Frankel John Hoey Edward Komoroski Robert Fratesi Thomas Hoey Irwin Korngold Burton Friedman Robert Holtaway John Kowallo VALOR AWARD MEMBERSHIP Neil Abilabilo Joseph Bonn Alan Connors Sr William Ackerson Robert Bosch Alan Connors, Jr Patricia Adochlo Gary Bossert Donald Conover Robert Adochio Kevin Boyle Paul Consiglio Wayne Altman Kenneth Brach William Constad William Anderson James Brady Christopher Cook Joseph Apuzzio William Brenner Barry Cooper Jack Argento George Brisebors Brian Cooper Lyle Armstrong Jr Richard Brisebois David Cooper Richard Aronwald Donald Broughton Foster Cooper George Athanasopoulos Donald Brown Meghan Cooper Officer Officer Officer James Aurelio Everett Brown Shannon Cooper Steven Cronce Robert Farrigan Robert Stober John Aversa George Bruggemeler Jr William Cooper III Richard Baccaro Blair Brygier William Cooper Sr On January 25th, 2010 at 3 55 am the Branchburg Police received a call from an employee of Gregory Bader Walter Brygier Jr Matthew Cooper, Jr the Quick Chek located on Route 22 The employee reported that there was an individual Yonghui Bader Robert Bukowczyk Angelo Corbo inside the store acting in a suspicious manner The employee described the individual as a Carla Corbo block male approximately 6'1 " wearing a military style packet and black cap Officer Steven John Bailye Gregory Burchette Cronce was the first officer to arrive on the scene Upon his arrival, Officer Cronce, wisely Lyndall Bailye John Burke Esther Corbo parked his patrol vehicle at the rear of the building and approached on foot This procedure John Balaskoms Thomas Burke John Corbo allowed him to view what was taking place inside the store and possibly prevent a hostage Thomas Baldwin Dan Burns * Robert Corcoran situation Marquerlte Baranowski Justin Burns Lawrence Corsini Officer Cronce observed the individual, later identified as Lloyd Woodson, picking up items Carlyle Caldwell Arthur Corsini Jr and putting them back on the shelf Officer Cronce subsequently entered the Quick Chek and Pasquale Barbieri walked post Mr Woodson Once inside the store Officer Cronce observed a large bulge under Francis Barbieri Jr Anne Cambria Gerald Cotter Mr Woodson's jacket which gave the appearance he was armed and possibly wearing a John Barna J Joseph Cambria Steven Cozza ballistic vest Christopher Bateman Joseph Cambria Kathleen Crabill At his point Officer Cronce decided to let Mr Woodson think his presence in the Quick Christopher Bateman James Cambria Jr Robert Cramer Jr Chek was routine This quick thinking kept Mr Woodson from panicking and causing potential Richard Capici David Critelli harm to the civilians present Joseph Bateman Officer Cronce moved toward the coffee area in an effort to keep some type of cover Raymond Bateman Paolo Capoferrl Daniel Crowe between him and Mr Woodson This also would allow Mr Woodson a free exit path from the David Batten Ray Caprlo John Cryan Jr store and possibly remove the threat from the civilians During this time Officer Cronce was John Beckwith Michael Cardone Joseph Cucchiaro able to speak briefly with the store manager to ascertain if anyone else was with Mr Woodson ' Paul Bell Graham Carley Joseph Cucchiaro At this point, Mr Woodson ran out of the store Officer Cronce was unable to detect Mr Bellina Dean Carman Philip Cuchiaro Woodson's direction of travel and did not know if he fled in an awaiting vehicle Officer Robert Cronce radioed Officer Robert Farngan and Officer Robert Stober, who were responding as Ralph Bencivenga Joseph Caro Thomas Cuozzo back up, that the suspect fled the store and that he appeared armed and wearing a Anthony Bendettl Anthony Caruso Richard Czachorowski bulletproof vest David Benenati Domenick Caruso Ronald Czatkowskl The three officers began to search the immediate area on foot in an effort to locate the George Bennett Joseph Caruso Gregg Da Graca suspect Several minutes later Officer Cronce observed Mr Woodson lying in the hedges near Marc Benou Dominick Caruson III Jack Dalton the Regency Tra+ter Park He drew his service weapon and ordered Mr Woodson to show his hands Mr Woodson would not comply and after several commands he stiff did not comply Robert Benou Robert Castronovo Daniel Dameo Against the instructions of Officer's Cronce, Farrigan and Stober, Mr Woodson rose to his feet Peter Bernabiti Thomas Castronovo Dorothy Dameo He was ordered to the ground and wouid not comply Mr Woodson then ran with the officers David Bernstein Lawrence Catena Jason Dameo in pursuit Officer Farrrgan grabbed his jacket and Mr Woodson pushed him off After Gary Bernstein Paul Cernuto Joan Dameo continuing the foot pursuit for thirty yards Officer Forrigan was able to trip Mr Woodson Kenneth Bernstein George Chandler Sr Rand Dameo causing him to fall to the ground Mr Woodson continued to fight the officers During the struggle they observed a rifle under his locket In an attempt to control Mr Woodson, Officer Michael Bessasparis Charles Chapin ' Rocque D Dameo Stober and Officer Cronce sprayed him with 0 C pepper spray This had minimal effect on him Ron Brava Gregg Chaplin Rocque Dameo and he continued to fight After several minutes of struggling with Mr Woodson the officers Barbara Biglow Jacobus Gary Christman Virginia Dameo Kraeutler were able to secure him in handcuffs Rachel Bilia James Cicalese Susan Danberry A search of Mr Woodson's person revealed he was in possession of a 50 caliber William Birch Robert Citron Fred Daniel Bushmaster military assault rifle, four magazines loaded with hollow point bullets and a military style ballistic vest Once Mr Woodson was secured bock at the Branchburg Police Floyd Bishop Patrick Coakley Toby Dattolo Headquarters he told the officers that while they were searching for him, he had them in his Alan Bitterman Peter Cocoziello Fernando DaVeiga rifle sight, but did not pull the trigger, Stephen Blank Peter Cocoziello, Jr Michael De Cou During the questioning of Mr Woodson it was learned that he was staying in one of the John Blauvelt Anthony Colaluca George Dealaman Jr rooms of the Red Mill Inn located in Branchburg Mr Woodson gave consent to search his room Denise Colaluca Joseph DeAngelis which uncovered a cache of weapons, including a homemade grenade launcher Carl Bleeker Lloyd Woodson was charged with attempted robbery of the Quick Chek, unlawful Alan Blitzer Donald Colanduont Dominick DeAngelo possession of an assault firearm possession of hollow point bullets, possession of high capacity Lester Bloch George Collins Jonathan Dee magazines and resisting arrest Phyllis Blythe James Collins David Deitz Subsequent to the arrest, information regarding the incident was sent out notionally It was Robert Bogle James Collins Anthony Delia learned that the Fairfax Virginia Police had an unsolved robbery similar in nature to the Scott Collins Valentino Della Pello attempted robbery of the Branchburg Quick Chek Surveillance video in the Virginia robbery Jay Bond clearly showed the actor was Lloyd Woodson With the information and evidence obtained Edward Bontakowski Colleen Colonna Vincent Della Pello from Branchburg, Fairfax Virginia Police charged Mr Woodson with armed robbery Joseph Boniakowski Dina Confalone Anthony Delucia Thomas Boniakowski Michael Conforti Carla Delucia Bill Bonnell Lori Connors Marv Delucia VALOR AWARD VALOR AWARD
Corporal Corporal Officer Michael Price Daniel McNamara George Obiedzinski
morning January 19, On August 10, 2010 Corporal Michael Price, a 25 year On the of Tuesday, 2010 while on routine patrol on South Bridge Street at approximately 0934 hours, Officer veteran, and Corporal Daniel McNamara, an 18 year Obiedzinski's attention was drawn to a green, two door Dodge that veteran, of the Franklin Township Police Department were was traveling south on South Bridge Street dispatched to a 9-1-1 call reporting an incident of The operator of the vehicle sounded his horn several times in quick succession as he passed Officer Obiedzinski Believing that the driver of that her father was domestic violence. The caller reported the green Dodge was attempting to get his attention and was in need physically assaulting her mother. Upon arrival, Corporals of assistance, Officer Obiedz nski followed the vehicle as vehicle as it Price and McNamara encountered the male subject in turned onto Holly Glen Road the rear detached garage of the residence. Corporal Upon pulling next to the vehicle on Holly Glen, Officer Obiedzinski encountered the actor who was standing outside his vehicle yelling McNamara spoke with the male subject while Corporal obscenities at Officer Obiedzinski Also visible inside the vehicle was a Price went to house and spoke to the caller and the large axe Realizing that he was not dealing with a citizen in need of female party. It was determined that as a result of this assistance, Officer Obiedzinski activated his emergency lights and his patrol car behind the suspect's vehicle. He then incident the male subject was going to be arrested for positioned exited his patrol car and ordered the actor to return to his vehicle. The actor domestic violence assault. Corporal Price advised the returned to his vehicle, not to comply with the officer's commands, but subject he was under arrest. As Corporals Price and to arm himself with a long handled axe and sledge hammer, carrying McNamara attempted to arrest the subject he struggled one in each hand As he advanced towards Officer Obiedzinski, Officer Obiedzinkski the front and fled. They took chase as the suspect ran to gave him verbal commands to stop and drop the weapons, to which of the residence. As the officers attempted to stop the the suspect responded "Do what you gotta do" At this time Officer subject, he produced a small caliber handgun and Obiedzinski drew his weapon and took a position of cover behind his pointed it at the officers. Corporal Price fired a single patrol car The subject, who was now yelling, proceeded to smash out the driver's side rear door window and windshield After smashing the round that struck the subject They then immediately windshield he advanced on Officer Obiedzinski, who while in fear for his rendered first aid until back-up officers and emergency life, discharged his service weapon twice, striking him and ending the medical personnel arrived. threat Once he was under control, Officer Obiedzinski attempted to call for paramedics to treat his injuries Form 8868 Application for Extension of Time To File ar (Rev January 2011) Exempt Organization Return OMB No 1545-1709
Department of the Treasury Internal Revenue Service File a separate application for each return. • If you are filing for an Automatic 3-Month Extension , complete only Part I and check this box • If you are filing for an Additional (Not Automatic) 3-Month Extension , complete only Part II (on page 2 of this form). Do not complete Part // unless you have already been granted an automatic 3-month extension on a previously filed Form 8868 Electronic filing (e-file). You can electronically file Form 8868 if you need a 3-month automatic extension of time to file (6 months for a corporation required to file Form 990-T), or an additional (not automatic) 3-month extension of time You can electronically file Form 8868 to request an extension of time to file any of the forms listed in Part I or Part II with the exception of Form 8870, Information Return for Transfers Associated With Certain Personal Benefit Contracts, which must be sent to the IRS in paper format (see instructions) For more details on the electronic filing of this form, visit www irs goviefile and click on e-file for Charities & Nonprofits Part I Automatic 3-Month Extension of Time. Only submit original (no copies needed) A corporation required to file Form 990-T and requesting an automatic 6-month extension - check this box and complete Part I only F1 All other corporations (including 1120-C filers), partnerships, REMICS, and trusts must use Form 7004 to request an extension of time to file Income tax returns Name of exempt organization FEnployer identification number Type or print The 200 Club of Somerset County 22-2588956 File by the Number, Street , and room or suite number If a P 0 box, see instructions due date for filing your return See P.O. Box 477 instructions City, town or post off ice , state, and ZIP code For a foreign address , see instruct ions Somerville, NJ 08876
Enter the Return code for the return that this application is for (file a separate application for each return) O1
Application Return Application Return Is For Code Is For Code Form 990 01 Form 990-T (corporation) 07 Form 990-BL 02 Form 1041-A 08 Form 990-EZ 03 Form 4720 09 Form 990-PF 04 Form 5227 10 Form 990-T (section 401(a) or 408(a) trust) 05 Form 6069 11 Form 990-T (trust other than above) 06 Form 8870 12
• The books are in the care of The Treasurer ► ------
Telephone No 908-722-6400 FAX No ► ------• If the organization does not have an office or place of business in the United States , check this box • If this is for a Group Return, enter the organization ' s four digit Group Exemption Number (GEN) If this is for the whole group, check this box 0-0 If it is for part of the group , check this box and attach a list with the names and ENS of all members the extension is for 1 I request an automatic 3-month (6 months for a corporation required to file Form 990 - T) extension of time until 6/1 5_ , 20 1 2 , to file the exempt organization return for the organization named above The extension is for the organization 's return for calendar year 20 or HX tax year beginning 11/01___ , 20 10_, and ending 10/31___ , 20 11
2 If the tax year entered in line 1 is for less than 12 months , check reason FlInitial return F]Final return F]Change in accounting period
3a If this application is for Form 990-BL, 990 -PF, 990-T, 4720, or 6069, enter the tentative tax, less any nonrefundable credits See instructions 0. b If this application is for Form 990-PF, 990-T, 4720, or 6069, enter any refundable credits and estimated tax payments made Include any prior year overpayment allowed as a credit 3b $ 0.
c Balance due. Subtract line 3b from line 3a Include your payment with this form, if required, by using EFTPS (Electronic Federal Tax Payment System) See instructions 0. Caution . If you are going to make an electronic fund withdrawal with this Form 8868, see Form 8453-EO and Form 8879-EO for payment instructions BAA For Paperwork Reduction Act Notice, see Instructions. Form 8868 (Rev 1-2011)
FIFZ0501L 11/15/10 Form 8868 (Rev 1-2011) Page 2 • If you are filing for an Additional (Not Automatic) 3-Month Extension , complete only Part II and check this box Note . Only complete Part II if you have already been granted an automatic 3-month extension on a previously filed Form 8868 • If you are filing for an Automatic 3-Month Extension , complete only Part I (on page 1) Part lI Additional (Not Automatic) 3-Month Extension of Time. Only file the orlalnal (no copies needed). Name of exempt organization Employer identification number
Type or print The 200 Club of Somerset County 22-2588956 Number. street , and room or suite number if a P 0 box, see instructions File by the extended Gillen & Johnson, P.A. due date for filing the 182 W. High St.- P.O. Box 477 return See instructions City, town or post office , state, and ZIP code For a fore ign address , see i nstructions Somerville, NJ 08876
Enter the Return code for the return that this application is for (file a separate application for each return) O1
lication Return App Ap plication Return Is For Code IsFor Code Form 990 01 Form 990-BL 02 Form 1041-A 08 Form 990-EZ 03 Form 4720 09 Form 990-PF 04 Form 5227 10 Form 990-T (section 401(a) or 408(a) trust) 05 Form 6069 11 Form 990-T (trust other than above) 06 Form 8870 12 STOP! Do not complete Part II if you were not already granted an automatic 3-month extension on a previously filed Form 8868. • The books are in care of - The Treasurer ------Telephone No 1` 908-722-6400 FAX No ------• If the organization does not have an office or place of business in the United States, check this box • If this is for a Group Return, enter the organization's four digit Group Exemption Number (GEN) If this is for the whole group, check this box F1 If it is for part of the group, check this box and attach a list with the names and EINs of all members the extension is for e 4 I request an additional 3-month extension of time until _ 9/15_ _ _ _ _ , 20 12 5 For calendar year _ _ _ or other tax year beginning 11/01_ _ _ _ _ , 20 _10 , and ending _10/31 _ _ _ _ , 20 11 6 If the tax year entered In line 5 is for less than 12 months, check reason n initial return Final return fl Change in accounting period 7 State in detail why you need the extension Taxjayer respectfully requests-additional_time_to _ ------_g ather-information_necessa to file a_complete and accurate tax return,
8a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any
b If this application is for Form 990 - PF, 990-T, 4720, or 6069 , enter any refundable credits and estimated tax payments made Include any prior year overpayment allowed as a credit and any amount paid previously with Form 8868 81b $ c Balance due. Subtract line 8b from line 8a Include your payment with this form, if required, by using EFTPS (Electronic Federal Tax Payment System) See Instructions 8c $ Signature and Verification Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief. is true. correct, and complete, and that I am authorized to prepare this form
Title 0" Date BAA FIFZ0502L 11/15/10 Form 8868 (Rev 1-2011)