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Return of Organization Exempt from Income

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Return of Organization Exempt from Income 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
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