Form990-EZ
Click to see list of attachments
Department of the Treasury
Internal Revenue Service
Short Form
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code
(except black lung benefit trust or private foundation)
bullet Sponsoring organizations of donor advised funds, organizations that operate one or more hospital facilities, and certain controlling organizations as defined in section 512(b)(13) must file Form 990 (see instructions).
All other organizations with gross receipts less than $200,000 and total assets less than $500,000 at the end of the year may use this form.
bulletThe organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-1150
2010
Open to Public
Inspection
A
For the 2010 calendar year, or tax year beginning 01-01-2010, and ending 12-31-2010
B
Check if applicable:
C Name of organization
KEYSTONE CHAPTER AMERICAN COLLEGE OF SURGEONS
 
Number and street (or P. O. box, if mail is not delivered to street address)777 EAST PARK DRIVE PO BOX 8820
  Room/suite
City or town, state or country, and ZIP + 4 HARRISBURG, PA17105
D Employer identification number

23-2083532
E Telephone number

(717) 558-7750
F Group Exemption
Number. . bullet  
G Accounting method: Other (specify) bullet   H Check bulletI Website:bulletWWW.KEYSTONESURGEONS.ORGJ Tax-Exempt status(check only one)—( 6) bullet(insert no.) or
K Check bullet A Form 990-EZ or Form 990 return is not required though Form 990-N (e-postcard) may be required (see instructions). But if the organization chooses to file a return, be sure to file a complete return.
L Add lines 5b, 6c, and 7b, to line 9 to determine gross receipts; If gross receipts are $200,000 or more, or if total assets (Part II, line 25, column (B) below) are $500,000 or more, file Form 990 instead of Form 990-EZ.. . bullet $ 53,438
Part IRevenue, Expenses, and Changes in Net Assets or Fund Balances (See the instructions for Part I.) Check if the organization used Schedule O to respond to any question in this Part I . . . . . . . .
VerticalRevenue 1 Contributions, gifts, grants, and similar amounts received . . . . . . . . . 1 4,000
2 Program service revenue including government fees and contracts . . . . . . . 2 10,125
3 Membership dues and assessments . . . . . . . . . . . . . . 3 38,425
4 Investment income . . . . . . . . . . . . . . . . . . 4 826
5a Gross amount from sale of assets other than inventory . . . . 5a  
b Less: cost or other basis and sales expenses . . 5b  
c Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) . . 5c  
6 Gaming and fundraising events
a Gross income from gaming (attach Schedule G if greater than $15,000) 6a  
b Gross income from fundraising events (not including $   of contributions from fundraising events reported on line 1) (attach Schedule G if the sum of such gross income and contributions exceed $15,000) . . . . . . .
c Less: direct expenses from gaming and fundraising events . . . 6c  
d Net income or (loss) from gaming and fundraising events (Add lines 6a and 6b and subtract line 6c) 6d  
7a Gross sales of inventory, less returns and allowances . . . . 7a  
b Less: cost of goods sold . . . . . . . . . . 7b  
c Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) . . . . . . 7c  
8 Other revenue (describe in Schedule O) . . . . . . . . . 8 62
9 Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 . . . . . . . . . 9 53,438
VerticalExpenses 10 Grants and similar amounts paid (list in Schedule O) . . . . . . . . 10  
11 Benefits paid to or for members . . . . . . . . . . . . . . . 11 3,610
12 Salaries, other compensation, and employee benefits . . . . . . . . . . . 12  
13 Professional fees and other payments to independent contractors . . . . . . . . 13 4,252
14 Occupancy, rent, utilities, and maintenance . . . . . . . . . . . . . 14 1,007
15 Printing, publications, postage, and shipping . . . . . . . . . . . . 15 2,401
16 Other expenses (describe in Schedule O) . . . . . . . . . . 16 40,210
17 Total expenses. Add lines 10 through 16 . . . . . . . . . . . . 17 51,480
VerticalNetAssets 18 Excess or (deficit) for the year (Subtract line 17 from line 9) . . . . . . . . . 18 1,958
19 Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with
end-of-year figure reported on prior year’s return) . . . . . . . . . . . 19 37,809
20 Other changes in net assets or fund balances (explain in Schedule O) . . . . . . . 20 1,270
21 Net assets or fund balances at end of year. Combine lines 18 through 20 . . . . . Bullet 21 41,037
Part IIBalance Sheets Check if the organization used Schedule O to respond to any question in this Part II. . . . . . . . .

(See the instructions for Part II.)(A) Beginning of year(B) End of year
22Cash, savings, and investments . . . . . . . . . .
26,318
22
31,525
23Land and buildings . . . . . . . . . . . . .
 
23
 
24Other assets (describe in Schedule O) . . . . . .
27,864
24
29,706
25Total assets . . . . . . . . . . . . . .
54,182
25
61,231
26
Total liabilities (describe in Schedule O) . . . . .
16,373
26
20,194
27Net assets or fund balances (line 27 of column (B) must agree with line 21) .
37,809
27
41,037
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 10642I Form 990-EZ (2010)
Form 990-EZ (2010)
Page 2
Part IIIStatement of Program Service Accomplishments Check if the organization used Schedule O to respond to any question in this Part III . Expenses
(Required for section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts; optional for others.)
What is the organization's primary exempt purpose? THE EASTERN PENNSYLVANIA CHAPTER OF THE AMERICAN COLLEGE OF SURGEONS WAS INCORPORATED IN APRIL 1993, UNDER THE PENNSYLVANIA NONPROFIT CORPORATION LAW OF 1988. EFFECTIVE JANUARY 1, 2003, THE CHAPTER MERGED WITH THE CENTRAL PENNSYLVANIA CHAPTER OF THE AMERICAN COLLEGE OF SURGEONS, INC. AND CHANGED ITS NAME TO THE KEYSTONE CHAPTER, AMERICAN COLLEGE OF SURGEONS, INC. THE PURPOSE OF THE CHAPTER IS TO ELEVATE THE STANDARDS OF SURGERY AND TO EDUCATE THE PROFESSION AND THE PUBLIC REGARDING THE SPECIAL TRAINING INVOLVED IN THE PRACTICE OF SURGERY. IN ADDITION, THE CHAPTER UNITES MEMBERS IN THEIR EFFORTS TO IMPROVE THE QUALITY OF SURGICAL PATIENT CARE AND PROVIDES A MEDIUM THROUGH WHICH SURGICAL EXPERIENCES MAY BE PRESENTED.
Describe what was achieved in carrying out the organization's exempt purposes. In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title.
28 THE CHAPTER HOLDS AN ANNUAL MEETING WHERE MEMBERS AND NON-MEMBER ATTENDEES QUALIFY FOR EDUCATION CREDITS. THE CHAPTER UNITES MEMBERS IN EFFORTS TO IMPROVE QUALITY OF SURGICAL PATIENT CARE, ELEVATE STANDARDS, EDUCATE THE PROFESSION AND THE PUBLIC RE: SPECIALIZED TRAINING INVOLVED IN THE PRACTICE OF SURGERY.
(Grants $ 0) If this amount includes foreign grants, check here ...MediumBullet		 28a 51,480
29
(Grants $   ) If this amount includes foreign grants, check here ...MediumBullet 		29a
30
(Grants $   ) If this amount includes foreign grants, check here ...MediumBullet 		30a
31 Other program services (describe in Schedule O) . . . . . . . . . . . .
(Grants $   ) If this amount includes foreign grants, check here...MediumBullet		 31a
32 Total program service expenses (add lines 28a through 31a) . . . . . . . . . bullet 32 51,480
Part IVList of Officers, Directors, Trustees, and Key Employees. List each one even if not compensated. (See the instructions for Part IV.) Check if the organization used Schedule O to respond to any question in this Part IV . . . . . . . .
(a) Name and address (b) Title and average
hours per week
devoted to position		 (c) Compensation
(If not paid,
enter -0-.) 		(d) Contributions to
employee benefit plans &
deferred compensation		 (e) Expense
account and
other allowances
DAVID ARBUTINA MD FACS
777 EAST PARK DRIVE
HARRISBURG,PA17105
 PRESIDENT0.25 0 0 0
CHRISTOPHER PAUL COPPOLA MD FACS
777 EAST PARK DRIVE
HARRISBURG,PA17105
 PRESIDENT ELECT0.25 0 0 0
DALE DANGLEBEN MD FACS
777 EAST PARK DRIVE
HARRISBURG,PA17105
 SECRETARY / TREASURER0.25 0 0 0
COLLIN MYERS MD FACS
777 EAST PARK DRIVE
HARRISBURG,PA17105
 IMMEDIATE PAST PRESIDENT0.25 0 0 0
ANTHONY DIPPOLITO MD FACS
777 EAST PARK DRIVE
HARRISBURG,PA17105
 ACS GOVERNOR-AT-LARGE0.25 0 0 0
EDWIN SHEARBURN III MD FACS
777 EAST PARK DRIVE
HARRISBURG,PA17105
 ACS GOVERNOR-AT-LARGE0.25 0 0 0
RANDALL CULP MD FACS
777 EAST PARK DRIVE
HARRISBURG,PA17105
 REGION 1 COUNCILOR0.25 0 0 0
JOHN PAGAN MD FACS
777 EAST PARK DRIVE
HARRISBURG,PA17105
 REGION 1 COUNCILOR0.25 0 0 0
BRUCE GRONKIEWICZ MD FACS
777 EAST PARK DRIVE
HARRISBURG,PA17105
 REGION 2 COUNCILOR0.25 0 0 0
PAUL BROWN JR MD FACS
777 EAST PARK DRIVE
HARRISBURG,PA17105
 REGION 3 COUNCILOR0.25 0 0 0
JOSEPH BLANSFIELD MD FACS
777 EAST PARK DRIVE
HARRISBURG,PA17105
 REGION 4 COUNCILOR0.25 0 0 0
MARY J REED MD FACS
777 EAST PARK DRIVE
HARRISBURG,PA17105
 REGION 4 COUNCILOR0.25 0 0 0
Form 990-EZ (2010)
Form 990-EZ (2010)
Page 3
Part VOther Information(Note the statement requirements in the instructions for Part V.)YesNo Check if the organization used Schedule O to respond to any question in this Part V . . . .
33
Did the organization engage in any activity not previously reported to the IRS? If "Yes," provide a detailed description of each activity in Schedule O ..............
33
 
No
34
Were any significant changes made to the organizing or governing documents? If "Yes," attach a conformed copy of the amended documents if they reflect a change to the organization’s name. Otherwise, explain the change on Schedule O (see instructions). ...................
34
 
No
35
If the organization had income from business activities, such as those reported on lines 2, 6a, and 7a (among others), but not reported on Form 990-T, explain in Schedule O why the organization did not report the income on Form 990-T. ........................
a
Did the organization have unrelated business gross income of $1,000 or more or was it a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice, reporting, and proxy tax requirements?
35a
 
No
b
If "Yes," has it filed a tax return on Form 990-T for this year? (see instructions) ........
35b
 
 
36
Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets during the year? If “Yes,” complete applicable parts of Schedule N .............
36
 
No
37a
Enter amount of political expenditures, direct or indirect, as described in the instructions. bullet
37a
0
b
Did the organization file Form 1120-POL for this year? ...............
37b
 
 
38a
Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were
any such loans made in a prior year and still outstanding at the end of the tax year covered by this return?
38a
 
No
b
If “Yes,” complete Schedule L, Part II and enter the total amount involved .
38b
 
39
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on line 9 ......
39a
 
b
Gross receipts, included on line 9, for public use of club facilities ....
39b
 
40a
Section 501(c)(3) organizations. Enter amount of tax imposed on the organization during the year under:
section 4911 bullet   ; section 4912 bullet   ; section 4955 bullet  
b
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in any section 4958 excess benefit transaction during the year or did it engage in an excess benefit transaction in a prior year that has not been reported on any of its prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I. ....
40b
 
 
c
Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 4912, 4955, and 4958 ..bullet  
d
Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax on line 40c reimbursed by the organization ...................bullet  
e
All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter transaction? If "Yes," complete Form 8886-T. .................
40e
 
No
41List the states with which a copy of this return is filed. bulletPA
42aThe organization's books are in care of bulletANNETTE M WEAVER Telephone no. bullet (717) 558-7750
Located at bullet777 EAST PARK DRIVE
HARRISBURG,PA ZIP + 4bullet17105
b
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)?
Yes
No
42b
 
No
If “Yes,” enter the name of the foreign country: bullet  
See the instructions for exceptions and filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
c
At any time during the calendar year, did the organization maintain an office outside of the U.S.?
42c
 
No
If “Yes,” enter the name of the foreign country: bullet  
43.......bullet
and enter the amount of tax-exempt interest received or accrued during the tax year . . . bullet43
 
44a
Did the organization maintain any donor advised funds? If "Yes", Form 990 must be completed instead of
Yes
No
Form 990-EZ.. . . . . . . . . . . . . . . . . . . .
44a
 
No
b
Did the organization operate one or more hospital facilities during the year? If ‘Yes,’ Form 990 must be completed instead of Form990-EZ. . . . . . . . .
44b
 
No
c
Did the organization receive any payments for indoor tanning services during the year? . . . . . . .
44c
 
No
d
If 'Yes' to line 44c, has the organization filed a Form 720 to report these payments? If ‘No,’ provide an explanation in Schedule O. . . . . . . . .
44d
 
 
45
Is any related organization a controlled entity of the organization within the meaning of section 512(b)(13)? If ‘Yes,’ Form 990 and Schedule R must be completed instead of Form990-EZ. . . . . . . . .
45
 
No
45a
Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If ‘Yes,’ Form 990 and Schedule R must be completed instead of Form990-EZ. .
45a
 
No
46
Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I. . . . . . . . . .
46
 
No
Form 990-EZ (2010)
Form 990-EZ (2010)
Page 4
Part VI
Section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts only. All section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts must answer questions 47-49b and 52. Check if the organization used Schedule O to respond to any question in this Part VI . . . . . . . .
Yes
No
47
Did the organization engage in lobbying activities? If "Yes," complete Schedule C, Part II . . . .
47
 
 
48
Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E . . .
48
 
 
49a
Did the organization make any transfers to an exempt non-charitable related organization? . . . .
49a
 
 
b
If "Yes," was the related organization a section 527 organization? . . . . . . . . .
49b
 
 
50
Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key employees) who each received more than $100,000 of compensation from the organization. If there is none, enter "None."
(a) Name and address of each employee paid more than $100,000 (b) Title and average
hours per week
devoted to position		 (c) Compensation
 (d) Contributions to
employee benefit plans &
deferred compensation		 (e) Expense
account and
other allowances
 
50(f)
Total number of other employees paid over $100,000 . . . . . . . . . . . . . bullet  

51
Complete this table for the organization's five highest compensated independent contractors who each received more than $100,000 of compensation from the organization. If there is none, enter "None."
(a) Name and address of each independent contractor paid more than $100,000 (b) Type of service (c) Compensation
 
51(d)
Total number of other independent contractors each receiving over $100,000 . . . . . . . bullet  
52
Did the organization complete Schedule A? NOTE: All Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable trusts must attach a completed Schedule A ....................
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer's Use Only Preparer's
signatureBig Right Arrow 		Date
right pointing bullet image Preparer’s taxpayer identification number
(See instructions)
Firm’s name (or yours
if self-employed),
address, and ZIP + 4Big Right Arrow




 		EIN right pointing bullet image
Phone no. right pointing bullet image
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
Form 990-EZ (2010)

Additional Data


Software ID:  
Software Version:  

Form 990-EZ, Special Condition Description:
Special Condition Description
SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
KEYSTONE CHAPTER AMERICAN COLLEGE OF SURGEONS
 
Employer identification number

23-2083532
Identifier Return Reference Explanation
OTHER INVESTMENT INCOME FORM 990-EZ, PART I, LINE 4 INVESTMENT INCOME 826..
OTHER REVENUE FORM 990-EZ, PART I, LINE 8 DESCRIPTION: INTEREST INCOME. AMOUNT: 62.
OTHER EXPENSES FORM 990-EZ, PART I, LINE 16 DESCRIPTION: CONTRACTED SERVICES. AMOUNT: 36,322. DESCRIPTION: OTHER EXPENSES. AMOUNT: 859. DESCRIPTION: TRAVEL. AMOUNT: 1,300. DESCRIPTION: SUPPLIES. AMOUNT: 1,729. TOTAL TO FORM 990-EZ, LINE 16: 40,210.
OTHER CHANGES IN NET ASSETS FORM 990-EZ, PART I, LINE 20 DESCRIPTION: UNREALIZED GAIN ON INVESTMENTS. AMOUNT: 1,270.
OTHER ASSETS FORM 990-EZ, PART II, LINE 24 DESCRIPTION: ACCOUNTS RECEIVABLE. BEG. OF YEAR AMOUNT: 100. END OF YEAR AMOUNT: 0. DESCRIPTION: PREPAID EXPENSES. BEG. OF YEAR AMOUNT: 90. END OF YEAR AMOUNT: 125. DESCRIPTION: INVESTMENTS. BEG. OF YEAR AMOUNT: 27,674. END OF YEAR AMOUNT: 29,581.
OTHER LIABILITIES FORM 990-EZ, PART II, LINE 26 DESCRIPTION: ACCOUNTS PAYABLE. BEG. OF YEAR AMOUNT: 2,873. END OF YEAR AMOUNT: 2,444. DESCRIPTION: UNEARNED REVENUE. BEG. OF YEAR AMOUNT: 13,500. END OF YEAR AMOUNT: 17,750.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  

TY 2010 TransferPrsnlBnftContractsDecl
Name:
KEYSTONE CHAPTER AMERICAN COLLEGE OF SURGEONS
EIN: 23-2083532
Declaration:
THE ORGANIZATION DID NOT, DURING THE YEAR, RECEIVE ANY FUNDS, DIRECTLY,OR INDIRECTLY, TO PAY PREMIUMS ON A PERSONAL BENEFIT CONTRACT.THE ORGANIZATION, DID NOT, DURING THE YEAR, PAY ANY PREMIUMS, DIRECTLY,OR INDIRECTLY, ON A PERSONAL BENEFIT CONTRACT.