TY 2021 Form 990PF

Part II		Balance Sheets	Beginning of year	End of year
Part II		Balance Sheets	(a) Book Value	(b) Book Value	(c) Fair Market Value
	1	Cash—non-interest-bearing.............	1,828	39,352	39,352
	2	Savings and temporary cash investments.........	752,574	745,727	745,727
	3	Accounts receivable
		Less: allowance for doubtful accounts
	4	Pledges receivable
		Less: allowance for doubtful accounts
	5	Grants receivable.................
	6	Receivables due from officers, directors, trustees, and other
		disqualified persons (attach schedule) (see instructions).....
	7	Other notes and loans receivable (attach schedule)
		Less: allowance for doubtful accounts
	8	Inventories for sale or use..............
	9	Prepaid expenses and deferred charges..........
	10a	Investments—U.S. and state government obligations (attach schedule)
	b	Investments—corporate stock (attach schedule).......
	c	Investments—corporate bonds (attach schedule).......
	11	Investments—land, buildings, and equipment: basis
		Less: accumulated depreciation (attach schedule)
	12	Investments—mortgage loans.............
	13	Investments—other (attach schedule)..........
	14	Land, buildings, and equipment: basis
		Less: accumulated depreciation (attach schedule)
	15	Other assets (describe )
	16	Total assets (to be completed by all filers—see the
		instructions. Also, see page 1, item I)	754,402	785,079	785,079
	17	Accounts payable and accrued expenses..........
	18	Grants payable.................
	19	Deferred revenue.................
	20	Loans from officers, directors, trustees, and other disqualified persons
	21	Mortgages and other notes payable (attach schedule)......
	22	Other liabilities (describe )
	23	Total liabilities (add lines 17 through 22).........		0
		Foundations that follow FASB ASC 958, check here
		and complete lines 24, 25, 29 and 30.
	24	Net assets without donor restrictions...........
	25	Net assets with donor restrictions............
		Foundations that do not follow FASB ASC 958, check here
		and complete lines 26 through 30.
	26	Capital stock, trust principal, or current funds........
	27	Paid-in or capital surplus, or land, bldg., and equipment fund
	28	Retained earnings, accumulated income, endowment, or other funds	754,402	785,079
	29	Total net assets or fund balances (see instructions).....	754,402	785,079
	30	Total liabilities and net assets/fund balances (see instructions).	754,402	785,079

Part III

Analysis of Changes in Net Assets or Fund Balances

Total net assets or fund balances at beginning of year—Part II, column (a), line 29 (must agree with end-of-year figure reported on prior year’s return) ...............

754,402

Enter amount from Part I, line 27a .....................

53,755

Other increases not included in line 2 (itemize) bullet

Add lines 1, 2, and 3 ..........................

808,157

Decreases not included in line 2 (itemize) bullet

23,078

Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29 .

785,079

(a) List and describe the kind(s) of property sold (e.g., real estate, 2-story brick warehouse; or common stock, 200 shs. MLC Co.)		(b) How acquired P—Purchase D—Donation	(c) Date acquired (mo., day, yr.)	(d) Date sold (mo., day, yr.)
1a
b
c
d
e

(e) Gross sales price		(f) Depreciation allowed (or allowable)	(g) Cost or other basis plus expense of sale	(h) Gain or (loss) (e) plus (f) minus (g)
a
b
c
d
e

Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69
(i) F.M.V. as of 12/31/69	(j) Adjusted basis as of 12/31/69	(k) Excess of col. (i) over col. (j), if any
a
b
c
d
e

2	Capital gain net income or (net capital loss)	If gain, also enter in Part I, line 7 If (loss), enter -0- in Part I, line 7	2
3	Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
	If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0- in Part I, line 8 ...................		3

1a	Exempt operating foundations described in section 4940(d)(2), check here and enter “N/A" on line 1.
	Date of ruling or determination letter: (attach copy of letter if necessary–see instructions)
b	All other domestic foundations enter 1.39% (0.0139) of line 27b. Exempt foreign organizations enter 4% (0.04) of Part I, line 12, col. (b)
2	Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)	2
3	Add lines 1 and 2...........................	3	671
4	Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)	4
5	Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- .....	5	671
6	Credits/Payments:

a	2021 estimated tax payments and 2020 overpayment credited to 2021	6a
b	Exempt foreign organizations—tax withheld at source......	6b
c	Tax paid with application for extension of time to file (Form 8868)...	6c
d	Backup withholding erroneously withheld ...........	6d

7	Total credits and payments. Add lines 6a through 6d..............		7
8	Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached.		8	3
9	Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......		9	674
10	Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...		10
11	Enter the amount of line 10 to be: Credited to 2022 estimated tax	Refunded	11

(a) Name and address	(b) Title, and average hours per week devoted to position	(c) Compensation (If not paid, enter -0-)
William H Buttrill	Board Member 002.00	0
3490 State Street Crisfield,MD21817
Ronald T Lamot	Board Member 002.00	0
8304 Oliver Street New Carrollton,MD20784
Sandra C Brantner	Chairman 002.00	0
1157 Old Crellin Road Oakland,MD21550
Connie DeYoung	Board Member 002.00	0
1 Patriot Drive Dover,DE19904
Carl A Robinson	Secretary/Treasurer 004.00	0
12021 8th Street Laurel,MD20707

List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc.	Expenses
1	Direct assistance to families of youth suffering from medical conditions 11 recipients this fiscal year	19,000
2	Assistance with operating expenses of Elks Camp Barrett-a youth camp Also utilized by Scouts, both Boy and Girl for their activities, and Johns Hopkins Hosital for a handicapped Youth week.	1,500
3


4

Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2.	Amount
1


2


All other program-related investments. See instructions.
3

		(a) Corpus	(d) 2021
1 Distributable amount for 2021 from Part X, line 7			0
2 Undistributed income, if any, as of the end of 2021:
a Enter amount for 2020 only.......
b Total for prior years:20, 20, 20
3 Excess distributions carryover, if any, to 2021:
a From 2016......
b From 2017......	31,107
c From 2018......	34,026
d From 2019......	12,861
e From 2020......	38,133
f Total of lines 3a through e ........		116,127
4Qualifying distributions for 2021 from Part
XI, line 4: $ 20,500
a Applied to 2020, but not more than line 2a
b Applied to undistributed income of prior years (Election required—see instructions).....
c Treated as distributions out of corpus (Election required—see instructions)........
d Applied to 2021 distributable amount.....
e Remaining amount distributed out of corpus		20,500
5 Excess distributions carryover applied to 2021.
(If an amount appears in column (d), the same amount must be shown in column (a).)
6Enter the net total of each column as indicated below:
a Corpus. Add lines 3f, 4c, and 4e. Subtract line 5		136,627
b Prior years’ undistributed income. Subtract line 4b from line 2b ..........
c Enter the amount of prior years’ undistributed income for which a notice of deficiency has been issued, or on which the section 4942(a) tax has been previously assessed......
d Subtract line 6c from line 6b. Taxable amount —see instructions ...........
e Undistributed income for 2019. Subtract line 4a from line 2a. Taxable amount—see instructions .............
f Undistributed income for 2021. Subtract lines 4d and 5 from line 1. This amount must be distributed in 2022 ..........			0
7 Amounts treated as distributions out of corpus to satisfy requirements imposed by section 170(b)(1)(F) or 4942(g)(3) (Election may be required - see instructions) .......
8 Excess distributions carryover from 2016 not applied on line 5 or line 7 (see instructions) ...
9 Excess distributions carryover to 2022. Subtract lines 7 and 8 from line 6a ......		136,627
10 Analysis of line 9:
a Excess from 2017....	31,107
b Excess from 2018....	34,026
c Excess from 2019....	12,861
d Excess from 2020....	38,133
e Excess from 2021....	20,500

2a Enter the lesser of the adjusted net income from Part I or the minimum investment return from Part X for each year listed ..........	Tax year	Prior 3 years			(e) Total
	(a) 2021	(b) 2020	(c) 2019	(d) 2018	(e) Total
	0				0
b 85% (0.85) of line 2a .........
c Qualifying distributions from Part XI, line 4 for each year listed .....	20,500	55,000	12,861	34,026	122,387
d Amounts included in line 2c not used directly for active conduct of exempt activities ..........
e Qualifying distributions made directly for active conduct of exempt activities. Subtract line 2d from line 2c ....	20,500	55,000	12,861	34,026	122,387
3 Complete 3a, b, or c for the alternative test relied upon:
a “Assets" alternative test—enter:
(1) Value of all assets ......
(2) Value of assets qualifying under section 4942(j)(3)(B)(i)
b “Endowment" alternative test— enter 2/3 of minimum investment return shown in Part IX, line 6 for each year listed ..		11,530		22,684	34,214
c “Support" alternative test—enter:
(1) Total support other than gross investment income (interest, dividends, rents, payments on securities loans (section 512(a)(5)), or royalties) ....
(2) Support from general public and 5 or more exempt organizations as provided in section 4942(j)(3)(B)(iii)....
(3) Largest amount of support from an exempt organization
(4) Gross investment income

aThe name, address, and telephone number or e-mail address of the person to whom applications should be addressed:

William J Jernick Memorial Fund
Various local Elks Lodges
Various,MD21236
(410) 256-9691

bThe form in which applications should be submitted and information and materials they should include:

Requests must be submitted through local Elks Lodges

cAny submission deadlines:

None

dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:

Only for families with sick or handicapped children under the age of 21

3 Grants and Contributions Paid During the Year or Approved for Future Payment
Recipient	If recipient is an individual, show any relationship to any foundation manager or substantial contributor	Foundation status of recipient	Purpose of grant or contribution	Amount
Name and address (home or business)		Foundation status of recipient	Purpose of grant or contribution	Amount
aPaid during the year
Samantha Waltemire for Stella Walte 75 Yoemans Tale Lne Felton,DE19943	None	I	To assist family with child having B-Cell AL Leukemia	2,000
Med El Corporation USA for Logan Hinegardner 2645 Meridian Parkway Suite 100 Durham,NC27713	None	NC	Repair of external portion of hearing device not covered by insurance	1,500
Barbara Starkey for Mary Starkey PO Box 2995-14227 Annapolis,MD21404	None	I	Assist with home improvement for family with a special needs child	2,000
Jeremy and Kelly Snyder for Carson 592 Juniper Court Westminster,MD21158	None	I	Monies toward purchase of a service dog trained in diabetes assistance	1,000
Rehabilitation of Frederick Inc for Eleizabeth Andreen 107 Remington Cr Havre de Grace,MD21078	None	NC	Adaptive driver training fpr child with cerebral palsy	1,500
Elks Camp Barrett PO Box 258 Crownsville,MD21032	Sister 501c3 Organization	PC	Youth Camp operating expenses	1,500
Dave and Valerie Dexter for Willow 22212 Oriole Drive Great Mill,MD20634	None	I	Aid with treatment and other costs for child with B-Cell Lymphoblastic Leukemia	2,000
Sean and Danielle Moore for Jonah M 1209 Finneans Run Arnold,MD21012	None	I	Aid with treatment for child with Bianary Altresia	2,000
Alicia Barlow for Harry Barlow 29 W Reybold Dr Middlwtown,DE19709	None	I	Assist family that has two autistic children	2,000
Fred and Brianna Jarrett for Air Ja 8 Walters Way Pasadena,MD21122	None	I	Assist with purchase of ramp and chair lift for famility with child who was born with congenital malformations of the spine	2,000
Chesapeake Therapeutic Riding Center for Scarlet Ryan 2608 Rohe Dr Kingsville,MD21087	None	NC	Assist with core mobility improvement for child with Spastic Hemiglegia	1,000
Karyn Seville for Bradyn Seville 37672 Hickory Street Ocean View,DE19970	None	I	Assist with caregivers for autistic child whose parents are also ill	2,000
Total ................................. 3a				20,500

Line No.	Explain below how each activity for which income is reported in column (e) of Part XV-A contributed importantly to the accomplishment of the foundation’s exempt purposes (other than by providing funds for such purposes). (See instructions.)
4	The total income derived from investments is available for use. This income is used to assist families with
4	children under the age of 21 who have serious medical problems, and to assist Elks Camp Barrett a camp for
4	youth operations.
11	Contributions income is invested and becomes part of the restricted corpus

	Analysis of Revenue and Expenses (The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see instructions).)	(a) Revenue and expenses per books		(b) Net investment income	(d) Disbursements for charitable purposes (cash basis only)


1	Contributions, gifts, grants, etc., received (attach schedule)	26,398
2	Check .............
3	Interest on savings and temporary cash investments
4	Dividends and interest from securities...	48,302		48,302
5a	Gross rents............
b	Net rental income or (loss)
6a	Net gain or (loss) from sale of assets not on line 10
b	Gross sales price for all assets on line 6a
7	Capital gain net income (from Part IV, line 2)...			0
8	Net short-term capital gain.........
9	Income modifications...........
10a	Gross sales less returns and allowances
b	Less: Cost of goods sold....
c	Gross profit or (loss) (attach schedule).....
11	Other income (attach schedule).......
12	Total. Add lines 1 through 11........	74,700		48,302
13	Compensation of officers, directors, trustees, etc.
14	Other employee salaries and wages......
15	Pension plans, employee benefits.......
16a	Legal fees (attach schedule).........
b	Accounting fees (attach schedule).......
c	Other professional fees (attach schedule)....
17	Interest...............
18	Taxes (attach schedule) (see instructions)...		428
19	Depreciation (attach schedule) and depletion...
20	Occupancy..............
21	Travel, conferences, and meetings.......
22	Printing and publications..........
23	Other expenses (attach schedule).......		17
24	Total operating and administrative expenses.
	Add lines 13 through 23..........	445		0	0
25	Contributions, gifts, grants paid.......	20,500			20,500
26	Total expenses and disbursements. Add lines 24 and 25	20,945		0	20,500
27	Subtract line 26 from line 12:
a	Excess of revenue over expenses and disbursements	53,755
b	Net investment income (if negative, enter -0-)			48,302
c	Adjusted net income (if negative, enter -0-)...

3 Five highest-paid independent contractors for professional services (see instructions). If none, enter "NONE".
(a) Name and address of each person paid more than $50,000	(b) Type of service	(c) Compensation

Enter gross amounts unless otherwise indicated.	Unrelated business income		Excluded by section 512, 513, or 514		(e) Related or exempt function income (See instructions.)
1Program service revenue:	(a) Business code	(b) Amount	(c) Exclusion code	(d) Amount	(e) Related or exempt function income (See instructions.)
a
b
c
d
e
f
gFees and contracts from government agencies
2 Membership dues and assessments ....
3 Interest on savings and temporary cash investments ...........
4 Dividends and interest from securities ....
5 Net rental income or (loss) from real estate:
aDebt-financed property......
bNot debt-financed property.....
6 Net rental income or (loss) from personal property
7 Other investment income .....
8 Gain or (loss) from sales of assets other than inventory ............
9 Net income or (loss) from special events:
10 Gross profit or (loss) from sales of inventory
11 Other revenue: aContributions
b
c
d
e
12 Subtotal. Add columns (b), (d), and (e) ..					48,302

(a) Line No.	(b) Amount involved	(c) Name of noncharitable exempt organization	(d) Description of transfers, transactions, and sharing arrangements

Paid Preparer Use Only	Print/Type preparer's name	Preparer's Signature	Date	Check if self- employed	PTIN
	Firm's name				Firm's EIN
	Firm's address				Phone no.


(a) Name and address of each employee paid more than $50,000	(b) Title, and average hours per week devoted to position	(c) Compensation	(d) Contributions to employee benefit plans and deferred compensation	(e) Expense account, other allowances










Total number of other employees paid over $50,000...................

bApproved for future payment

Total ................................. 3b

Name of organization William J Jernick Memorial Fund Inc

Part I Contributors	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
1	Kent Island Elks Lodge 2525 Romancoke Road Stevensville, MD21666	$ 4,500	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990) (2021)

Name of organization William J Jernick Memorial Fund Inc		Employer identification number 52-2206999

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
Schedule B (Form 990) (2021)


Name of organization William J Jernick Memorial Fund Inc			Employer identification number 52-2206999
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) $ Use duplicate copies of Part III if additional space is needed.

Software ID:	21013554
Software Version:	21.0.5.0