Form990-EZ
Click to see attachment
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
2011
Open to Public
Inspection
A
For the 2011 calendar year, or tax year beginning 12-01-2011, and ending 11-30-2012
B
Check if applicable:
C Name of organization
WOLVERINE MUTUAL BENEFIT
ASSOCIATION
Number and street (or P. O. box, if mail is not delivered to street address)9341 COURTLAND DRIVE
  Room/suite
City or town, state or country, and ZIP + 4 ROCKFORD, MI49351
D Employer identification number

38-6091644
E Telephone number

(616) 866-5500
F Group Exemption
Number. . bullet  
G Accounting method: Other (specify) bullet   H Check bulletI Website:bulletN/AJ Tax-Exempt status(check only one)—( 9) 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 $ 9,780
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  
2 Program service revenue including government fees and contracts ............ 2  
3 Membership dues and assessments...................... 3 7,200
4 Investment income........................... 4 2,580
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 exceeds $15,000) 6b  
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  
9 Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8................. 9 9,780
VerticalExpenses 10 Grants and similar amounts paid (list in Schedule O) ................. 10  
11 Benefits paid to or for members........................ 11 34,200
12 Salaries, other compensation, and employee benefits................ 12 7,819
13 Professional fees and other payments to independent contractors............ 13 31,158
14 Occupancy, rent, utilities, and maintenance................... 14  
15 Printing, publications, postage, and shipping................... 15  
16 Other expenses (describe in Schedule O) .................... 16 140,453
17 Total expenses. Add lines 10 through 16 .................... 17 213,630
VerticalNetAssets 18 Excess or (deficit) for the year (Subtract line 17 from line 9)............ 18 -203,850
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)................ 19 202,554
20 Other changes in net assets or fund balances (explain in Schedule O) .......... 20 1,542
21 Net assets or fund balances at end of year. Combine lines 18 through 20.........Bullet 21 246
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 10642I Form 990-EZ (2011)
Form 990-EZ (2011)
Page 2
Part IIBalance Sheets (see the instructions for Part II.)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................
202,554
22
16,195
23Land and buildings....................
 
23
 
24Other assets (describe in Schedule O) ..........
 
24
 
25Total assets......................
202,554
25
16,195
26
Total liabilities (describe in Schedule O) .............
 
26
15,949
27Net assets or fund balances (line 27 of column (B) must agree with line 21)..
202,554
27
246
Part IIIStatement of Program Service Accomplishments (see the instructions for Part III.) 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? PROVIDE PARTIAL COMPENSATION FOR LOST WAGES DUE TO ILLNESS
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title.
28 BENEFIT PAYMENTS SICKNESS AND ACCIDENT TOTAL MEMBERSHIP AS OF 11-30-09 WAS 571
(Grants $   ) If this amount includes foreign grants, check here ...MediumBullet		 28a 34,200
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 34,200
Part IV List 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 title (b) Average
hours per week
devoted to position		 (c)Reportable compensation
(Forms W-2/1099-MISC)
(if not paid, enter -0-) 		(d) Health benefits, contributions to employee benefit plans,
and deferred compensation		 (e) Estimated amount
of other compensation
SUE SIMCOEClick to see attachment
9341 COURTLAND DRIVE
ROCKFORD,MI49351
 PRES/DIRECT.1.00 0    
KAREN INMANClick to see attachment
9341 COURLTAND DRIVE
ROCKFORD,MI49351
 SEC/TREAS6.00 5,354    
NANCY ZUFELTClick to see attachment
9341 COURLTAND DRIVE
ROCKFORD,MI49351
 ASSIST S/T3.00 1,573    
ELLEN BENGRYClick to see attachment
9341 COURLTAND DRIVE
ROCKFORD,MI49351
 DIRECTOR1.00 0    
JANET WILBURNClick to see attachment
9341 COURLTAND DRIVE
ROCKFORD,MI49351
 VP/DIRECTOR1.00 0    
CARLA WESTClick to see attachment
9341 COURTLAND DRIVE
ROCKFORD,MI49351
 DIRECTOR1.00 0    
SHEILA VANDER ZYLClick to see attachment
9341 COURTLAND DRIVE
ROCKFORD,MI49351
 DIRECTOR1.00 0    
Form 990-EZ (2011)
Form 990-EZ (2011)
Page 3
Part VOther Information(Note the Schedule A and personal benefit contract statement requirements in the instructions for Part V.) Check if the organization used Schedule O to respond to any question in this Part V
Yes
No
33
Did the organization engage in any significant 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 changeon Schedule O (see instructions). ..........................
34
 
No
35a
Did the organization have unrelated business gross income of $1,000 or more during the year from business activities (such as those reported on lines 2, 6a, and 7a, among others)? ............
35a
 
No
b
If ‘Yes’ to line 35a, has the organization filed a Form 990-T for the year? If ‘No,’ provide an explanation in Schedule O.
35b
 
 
c
Was the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice, reporting, and proxy tax requirements during the year? If "Yes," complete Schedule C, Part III.
35c
 
No
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 Click to see attachment................
36
Yes
 
37a
Enter amount of political expenditures, direct or indirect, as described in the instructions. bullet
37a
 
b
Did the organization file Form 1120-POL for this year?...................
37b
 
No
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 benefittransaction 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. bullet
42aThe organization's books are in care of bulletKAREN INMAN Telephone no. bullet (616) 866-5500
Located at bullet9341 COURTLAND DRIVE
ROCKFORD,MI ZIP + 4bullet493510001
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 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
 
Yes
No
44a
Did the organization maintain any donor advised funds during the year? If "Yes," Form 990 must be completed instead of
Form 990-EZ.................................
44a
 
No
b
Did the organization operate one or more hospital facilities during the year? If ‘Yes,’ Form 990 must be completedinstead 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 explanationin Schedule O................................
44d
 
 
45a
Did the organization have a controlled entity within the meaning of
section 512(b)(13)?............................
45a
 
No
45b
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 may need to be completed instead of Form990-EZ (see instructions).....................
45b
 
No
Form 990-EZ (2011)
Form 990-EZ (2011)
Page 4
Yes
No
46
Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition tocandidates for public office? If “Yes,” complete Schedule C, Part I. ..............
46
 
No
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 or have a section 501(h) election in effect during the tax year? 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 title of each employee paid more than $100,000 (b) Average
hours per week
devoted to position		 (c) Reportable compensation
(Forms W-2/1099-MISC) 		(d) Health benefits, contributions to employee benefit plans, and deferred compensation (e) Estimated amount of other compensation
 
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
 
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 use only
Print/type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name Right pointing arrowhead image

Firm's EIN Right pointing arrowhead image
Firm's address Right pointing arrowhead image



Phone no.
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
Form 990-EZ (2011)

Additional Data


Software ID:  
Software Version:  

Form 990-EZ, Special Condition Description:
Special Condition Description
SCHEDULE N
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Liquidation, Termination, Dissolution or Significant Disposition of Assets
bullet Complete if the organization answered "Yes" to Form 990, Part IV, lines 31 or 32 or Form 990-EZ, line 36.
bullet Attach certified copies of any articles of dissolution, resolutions or plans.
bullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
WOLVERINE MUTUAL BENEFIT
ASSOCIATION
Employer identification number
38-6091644
Part I
Liquidation, Termination or Dissolution. Complete if the organization answered "Yes" to Form 990, Part IV, line 31, or Form 990-EZ, line
36. Use Part III if additional space is needed.
1(a)Description of asset(s)
distributed or transaction
expenses paid		 (b)Date of
distribution		 (c)Fair market value of
asset(s) distributed or
amount of transaction
expenses		 (d)Method of
determining FMV for
asset(s) distributed or
transaction expenses		 (e)EIN of recipient (f)Name and address of recipient (g)IRC section
of recipient(s) (if
tax-exempt) or type
of entity
























Yes
No
2
Did or will any officer, director, trustee, or key employee of the organization:
a
Become a director or trustee of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . . .
2a
 
 
b
Become an employee of, or independent contractor for, a successor or transferee organization? . . . . . . . . . . . . . . . .
2b
 
 
c
Become a direct or indirect owner of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . .
2c
 
 
d
Receive, or become entitled to, compensation or other similar payments as a result of the organization's liquidation, termination, or dissolution? . . . . .
2d
 
 
e
If the organization answered "Yes" to any of the questions in this line, provide the name of the person involved and explain in Part III. bullet
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990 or Form 990-EZ.
Cat. No. 50087Z
Schedule N (Form 990 or 990-EZ) 2011

Schedule N (Form 990 or 990-EZ) 2011
Page 2
Part I
Liquidation, Termination or Dissolution (continued)
Note. If the organization distributed all of its assets during the tax year, then Form 990, Part X, column (B), line 16 (Total assets), and line 26 (Total liabilities), should equal -0-.
Yes
No
3
Did the organization distribute its assets in accordance with its governing instrument(s)? If “No,” describe in Part III . . . . . . . . . . .
3
 
 
4a
Is the organization required to notify the attorney general or other appropriate state official of its intent to dissolve, liquidate, or terminate? . . . . . .
4a
 
 
b
If “Yes,” did the organization provide such notice? . . . . . . . . . . . . . . . . . . . . . . . . . .
4b
 
 
5
Did the organization discharge or pay all of its liabilities in accordance with state laws? . . . . . . . . . . . . . . . . .
5
 
 
6a
Did the organization have any tax-exempt bonds outstanding during the year? . . . . . . . . . . . . . . . . . . . .
6a
 
 
b
Did the organization discharge or defease all of its tax-exempt bond liabilities during the tax year in accordance with the Internal Revenue Code and state laws? .
6b
 
 
c
If ‘Yes’ to line 6b, describe in Part III how the organization defeased or otherwise settled these liabilities. If “No,” explain in Part III.

Part II
Sale, Exchange, Disposition or Other Transfer of More Than 25% of the Organization's Assets. Complete if the organization answered "Yes" to Form 990, Part IV, line 32, or Form 990-EZ, line 36. Use Part III if additional space is needed.
1(a)Description of asset(s)
distributed or transaction
expenses paid		 (b)Date of
distribution		 (c)Fair market value of
asset(s) distributed or
amount of transaction
expenses		 (d)Method of
determining FMV for
asset(s) distributed or
transaction expenses		 (e)EIN of recipient (f)Name and address of recipient (g)IRC section
of recipient(s) (if
tax-exempt) or type
of entity
CASH 11-01-2012 137,218 CASH ALL MEMBERS
 
  		 


















Yes
No
2
Did or will any officer, director, trustee, or key employee of the organization:
a
Become a director or trustee of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . . .
2a
 
 
b
Become an employee of, or independent contractor for, a successor or transferee organization? . . . . . . . . . . . . . . . .
2b
 
 
c
Become a direct or indirect owner of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . . .
2c
 
 
d
Receive, or become entitled to, compensation or other similar payments as a result of the organization’s significant disposition of assets? . . . . . . .
2d
 
 
e
If the organization answered "Yes" to any of the questions in this line, provide the name of the person involved and explain in Part III.
Schedule N(Form 990 or 990-EZ) 2011

Schedule N (Form 990 or 990-EZ) 2011
Page 3
Part III
Supplemental Information. Complete to provide the information required by Parts I and II,
and any additional information.
Identifier Return Reference Explanation
Schedule N (Form 990 or 990-EZ) 2011


Additional Data


Software ID:  
Software Version:  


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
2011
Open to Public
Inspection
Name of the organization
WOLVERINE MUTUAL BENEFIT
ASSOCIATION
Employer identification number

38-6091644
Identifier Return Reference Explanation
OTHER EXPENSES FORM 990-EZ, PART I, LINE 16 EXPENSES BANK FEES 3,235 TERMINATION PAYOUT 137,218 TOTAL 140,453
OTHER CHANGES IN NET ASSETS OR FUND BALANCES FORM 990-EZ, PART I, LINE 20 NET APPRECIATION IN FAIR VALUE OF MUTUAL FUNDS 1,542
OTHER LIABILITIES FORM 990-EZ, PART II, LINE 26 ACCOUNTS PAYABLE AND ACCRUED EXPENSES 0 15,949
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  

TY 2011 CompensationExplanation
Name:
WOLVERINE MUTUAL BENEFIT
ASSOCIATION
EIN: 38-6091644
Person Name Explanation
SUE SIMCOE  
KAREN INMAN  
NANCY ZUFELT  
ELLEN BENGRY  
JANET WILBURN  
CARLA WEST  
SHEILA VANDER ZYL