JJS FOUNDATION INC: Form 990PF, tax year 2015
View the entire original 990 at ProPublica ↗
- Organization
- JJS FOUNDATION INC (EIN 27-0520587)
- Tax period
- 2015-01-01 to 2015-12-31
- Filed
- 2016-08-14
- IRS object ID
- 201602279349100300
- Schema version
- 2015v2.0
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990-PF
- Schedule B
- Accounting Fees Schedule
- Other Expenses Schedule
- Substantial Contributors Sch
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2016-08-14T07:47:50-07:00 | ReturnTs |
| Tax Period End | 2015-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | JAMES BOHL CPA PC | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 25 Johnson Ave | AddressLine1Txt |
| City | RONKONKOMA | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 11779 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990PF | ReturnTypeCd |
| Tax Period Begin | 2015-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 270520587 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | JJS FOUNDATION INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | JJSF | BusinessNameControlTxt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 201 CANAL ROAD | AddressLine1Txt |
| City | PORT JEFF STATION | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 11776 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | GRACE BOHL | PersonNm |
| Person Title | Secretary | PersonTitleTxt |
| Signature | 2016-08-14 | SignatureDt |
| Discuss With Paid Preparer | Yes (true) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | JAMES BOHL CPA | PreparerPersonNm |
| PTIN | P00183099 | PTIN |
| Phone | 6316764995 | PhoneNum |
| Self Employed | Yes (X) | SelfEmployedInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2015 | TaxYr |
| Build TS | 2016-12-15 16:53:06Z | BuildTS |
Form 990-PF IRS990PF
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization501c3 Exempt PF | Yes (X) | Organization501c3ExemptPFInd |
| FMV Assets EOY | $6,075 | FMVAssetsEOYAmt |
| Method Of Accounting Cash | Yes (X) | MethodOfAccountingCashInd |
Analysis Of Revenue And Expenses AnalysisOfRevenueAndExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contri Rcvd Rev And Expnss | $20,500 | ContriRcvdRevAndExpnssAmt |
| Interest On Sav Rev And Expnss | $1 | InterestOnSavRevAndExpnssAmt |
| Interest On Sav Net Invst Incm | $1 | InterestOnSavNetInvstIncmAmt |
| Interest On Savings Adj Net Incm | $1 | InterestOnSavingsAdjNetIncmAmt |
| Total Rev And Expnss | $20,501 | TotalRevAndExpnssAmt |
| Total Net Invst Incm | $1 | TotalNetInvstIncmAmt |
| Total Adj Net Incm | $1 | TotalAdjNetIncmAmt |
| Accounting Fees Rev And Expnss | $500 | AccountingFeesRevAndExpnssAmt |
| Trav Conf Meeting Rev And Expnss | $1,591 | TravConfMeetingRevAndExpnssAmt |
| Other Expenses Rev And Expnss | $7,027 | OtherExpensesRevAndExpnssAmt |
| Tot Opr Expenses Rev And Expnss | $9,118 | TotOprExpensesRevAndExpnssAmt |
| Tot Opr Expenses Net Invst Incm | $0 | TotOprExpensesNetInvstIncmAmt |
| Tot Opr Expenses Dsbrs Chrtbl | $0 | TotOprExpensesDsbrsChrtblAmt |
| Contri Paid Rev And Expnss | $14,956 | ContriPaidRevAndExpnssAmt |
| Contri Paid Dsbrs Chrtbl | $14,956 | ContriPaidDsbrsChrtblAmt |
| Total Expenses Rev And Expnss | $24,074 | TotalExpensesRevAndExpnssAmt |
| Total Expenses Net Invst Incm | $0 | TotalExpensesNetInvstIncmAmt |
| Total Expenses Dsbrs Chrtbl | $14,956 | TotalExpensesDsbrsChrtblAmt |
| Excess Revenue Over Expenses | -$3,573 | ExcessRevenueOverExpensesAmt |
| Net Investment Income | $1 | NetInvestmentIncomeAmt |
| Adjusted Net Income | $1 | AdjustedNetIncomeAmt |
Form990 PF Balance Sheets Form990PFBalanceSheetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cash BOY | $9,648 | CashBOYAmt |
| Cash EOY | $6,075 | CashEOYAmt |
| Cash EOYFMV | $6,075 | CashEOYFMVAmt |
| Total Assets BOY | $9,648 | TotalAssetsBOYAmt |
| Total Assets EOY | $6,075 | TotalAssetsEOYAmt |
| Total Assets EOYFMV | $6,075 | TotalAssetsEOYFMVAmt |
| Total Liabilities EOY | $0 | TotalLiabilitiesEOYAmt |
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
| Unrestricted BOY | $9,648 | UnrestrictedBOYAmt |
| Unrestricted EOY | $6,075 | UnrestrictedEOYAmt |
| Tot Net Ast Or Fund Balances BOY | $9,648 | TotNetAstOrFundBalancesBOYAmt |
| Tot Net Ast Or Fund Balances EOY | $6,075 | TotNetAstOrFundBalancesEOYAmt |
| Total Liabilities Net Ast BOY | $9,648 | TotalLiabilitiesNetAstBOYAmt |
| Total Liabilities Net Ast EOY | $6,075 | TotalLiabilitiesNetAstEOYAmt |
Chg In Net Assets Fund Balances ChgInNetAssetsFundBalancesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tot Net Ast Or Fund Balances BOY | $9,648 | TotNetAstOrFundBalancesBOYAmt |
| Excess Revenue Over Expenses | -$3,573 | ExcessRevenueOverExpensesAmt |
| Subtotal | $6,075 | SubtotalAmt |
| Tot Net Ast Or Fund Balances EOY | $6,075 | TotNetAstOrFundBalancesEOYAmt |
Excise Tax Based On Invst Incm ExciseTaxBasedOnInvstIncmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Income Excise Tax | $0 | InvestmentIncomeExciseTaxAmt |
Statements Regarding Acty StatementsRegardingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Legislative Political Acty | false | LegislativePoliticalActyInd |
| More Than100 Spent | false | MoreThan100SpentInd |
| Form1120 POL Filed | false | Form1120POLFiledInd |
| Activities Not Previously Rpt | false | ActivitiesNotPreviouslyRptInd |
| Changes To Articles Or Bylaws | false | ChangesToArticlesOrBylawsInd |
| Unrelated Bus Incm Over Limit | false | UnrelatedBusIncmOverLimitInd |
| Form990 T Filed | false | Form990TFiledInd |
| Organization Dissolved Etc | false | OrganizationDissolvedEtcInd |
| Section508e Rqr Satisfied | false | Section508eRqrSatisfiedInd |
| At Least5000 In Assets | Yes (true) | AtLeast5000InAssetsInd |
| Org Report Or Register State | NY | OrgReportOrRegisterStateCd |
| Form990 PF Filed With Atty Gen | Yes (true) | Form990PFFiledWithAttyGenInd |
| Private Operating Foundation | false | PrivateOperatingFoundationInd |
| New Substantial Contributors | Yes (true) | NewSubstantialContributorsInd |
| Own Controlled Entity | false | OwnControlledEntityInd |
| Donor Advised Fund | false | DonorAdvisedFundInd |
| Comply With Public Insp Rqr | Yes (true) | ComplyWithPublicInspRqrInd |
| Website Address | N/A | WebsiteAddressTxt |
Persons With Books Name PersonsWithBooksName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GRACE BOHL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 6314671972 | PhoneNum |
Location Of Books US Address LocationOfBooksUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 61 FOREST DRIVE | AddressLine1Txt |
| City | RONKONKOMA | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 11779 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Foreign Accounts Question | false | ForeignAccountsQuestionInd |
Statements Regarding Acty4720 StatementsRegardingActy4720Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Sale Or Exch Disqualified Prsn | false | SaleOrExchDisqualifiedPrsnInd |
| Brrw Or Lend Disqualified Prsn | false | BrrwOrLendDisqualifiedPrsnInd |
| Furn Goods Disqualified Prsn | false | FurnGoodsDisqualifiedPrsnInd |
| Pay Comp Disqualified Prsn | false | PayCompDisqualifiedPrsnInd |
| Transfer Ast Disqualified Prsn | false | TransferAstDisqualifiedPrsnInd |
| Payment To Government Official | false | PaymentToGovernmentOfficialInd |
| Acts Fail To Qlfy As Exceptions | false | ActsFailToQlfyAsExceptionsInd |
| Uncorrected Prior Acts | false | UncorrectedPriorActsInd |
| Undistributed Income PY | false | UndistributedIncomePYInd |
| Undistr Incm Sect4942a2 Not App | false | UndistrIncmSect4942a2NotAppInd |
| Business Holdings | false | BusinessHoldingsInd |
| Excess Business Holdings | false | ExcessBusinessHoldingsInd |
| Jeopardy Investments | false | JeopardyInvestmentsInd |
| Uncorrected PY Jeopardy Invst | false | UncorrectedPYJeopardyInvstInd |
| Influence Legislation | false | InfluenceLegislationInd |
| Influence Election | false | InfluenceElectionInd |
| Grants To Individuals | false | GrantsToIndividualsInd |
| Grants To Organizations | false | GrantsToOrganizationsInd |
| Noncharitable Purpose | false | NoncharitablePurposeInd |
| Transactions Fail To Qlfy As Exc | false | TransactionsFailToQlfyAsExcInd |
| Maintained Expenditure Rspns | false | MaintainedExpenditureRspnsInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | false | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | false | PayPremiumsPrsnlBnftCntrctInd |
| Prohibited Tax Shelter Trans | false | ProhibitedTaxShelterTransInd |
| Proceeds Or Net Income | false | ProceedsOrNetIncomeInd |
Officer Dir Trst Key Empl Info OfficerDirTrstKeyEmplInfoGrp
Officer Dir Trst Key Empl OfficerDirTrstKeyEmplGrp (3 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | TitleTitleTxt | Average Hrs Per Wk Devoted To PosAverageHrsPerWkDevotedToPosRt | CompensationCompensationAmt |
|---|---|---|---|---|---|---|
| JACK SEFERIAN | ||||||
| 201 CANAL ROAD | PORTJEFFERSON STATION | NY | 11776 | President | 1.00 | $0 |
| HAIG SEFERIAN | ||||||
| 188 OLD FIELD ROAD | SETAUKET | NY | 11733 | Vice President | 1.00 | $0 |
| GRACE BOHL | ||||||
| 61 FOREST DRIVE | RONKONKOMA | NY | 11779 | Secretary | 20.00 | $0 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Comp Of Hghst Pd Empl Or NONE | NONE | CompOfHghstPdEmplOrNONETxt |
| Comp Of Hghst Pd Cntrct Or NONE | NONE | CompOfHghstPdCntrctOrNONETxt |
Minimum Investment Return MinimumInvestmentReturnGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Average Monthly FMV Of Sec | $0 | AverageMonthlyFMVOfSecAmt |
| Average Monthly Cash Balances | $0 | AverageMonthlyCashBalancesAmt |
| FMV All Other Noncharitable Ast | $0 | FMVAllOtherNoncharitableAstAmt |
| Total FMV Of Unused Assets | $0 | TotalFMVOfUnusedAssetsAmt |
| Reduction Claimed | $0 | ReductionClaimedAmt |
| Adjusted Total FMV Of Unused Ast | $0 | AdjustedTotalFMVOfUnusedAstAmt |
| Cash Deemed Charitable | $0 | CashDeemedCharitableAmt |
| Net Vl Noncharitable Assets | $0 | NetVlNoncharitableAssetsAmt |
| Minimum Investment Return | $0 | MinimumInvestmentReturnAmt |
Distributable Amount DistributableAmountGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Distributable As Adjusted | $0 | DistributableAsAdjustedAmt |
Qualifying Distri Part XII QualifyingDistriPartXIIGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expenses And Contributions | $14,956 | ExpensesAndContributionsAmt |
| Qualifying Distributions | $14,956 | QualifyingDistributionsAmt |
| Adjusted Qualifying Distri | $14,956 | AdjustedQualifyingDistriAmt |
Undistributed Income UndistributedIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Distributable As Adjusted | $0 | DistributableAsAdjustedAmt |
| Excess Distribution Cyov Yr5 | $13,216 | ExcessDistributionCyovYr5Amt |
| Excess Distribution Cyov Yr4 | $14,780 | ExcessDistributionCyovYr4Amt |
| Excess Distribution Cyov Yr3 | $10,910 | ExcessDistributionCyovYr3Amt |
| Excess Distribution Cyov Yr2 | $9,511 | ExcessDistributionCyovYr2Amt |
| Excess Distribution Cyov Yr1 | $13,196 | ExcessDistributionCyovYr1Amt |
| Total Excess Distribution Cyov | $61,613 | TotalExcessDistributionCyovAmt |
| Qualifying Distributions | $14,956 | QualifyingDistributionsAmt |
| Treated As Distri From Corpus | $0 | TreatedAsDistriFromCorpusAmt |
| Remaining Distri From Corpus | $14,956 | RemainingDistriFromCorpusAmt |
| Total Corpus | $76,569 | TotalCorpusAmt |
| Undistributed Income CY | $0 | UndistributedIncomeCYAmt |
| Excess Distri Cyov From Yr5 | $13,216 | ExcessDistriCyovFromYr5Amt |
| Excess Distri Cyov To Next Yr | $63,353 | ExcessDistriCyovToNextYrAmt |
| Excess From Year4 | $14,780 | ExcessFromYear4Amt |
| Excess From Year3 | $10,910 | ExcessFromYear3Amt |
| Excess From Year2 | $9,511 | ExcessFromYear2Amt |
| Excess From Year1 | $13,196 | ExcessFromYear1Amt |
| Excess From Current Year | $14,956 | ExcessFromCurrentYearAmt |
Supplementary Information SupplementaryInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributing Manager | JACK SEFERIAN | ContributingManagerNm |
| Only Contri To Preselected | Yes (X) | OnlyContriToPreselectedInd |
Grant Or Contribution Pd Dur Yr GrantOrContributionPdDurYrGrp (13 entries)
| Address Line1RecipientUSAddress/AddressLine1Txt | CityRecipientUSAddress/CityNm | State AbbreviationRecipientUSAddress/StateAbbreviationCd | ZIPRecipientUSAddress/ZIPCd | Recipient RelationshipRecipientRelationshipTxt | Recipient Foundation StatusRecipientFoundationStatusTxt | Grant Or Contribution PurposeGrantOrContributionPurposeTxt | AmtAmt |
|---|---|---|---|---|---|---|---|
| BARBAR'S TEAM OF HOPE | |||||||
| 122 MCKINLEY STREET | MASSAPEQUA | NY | 11762 | NONE | 501(c)(3) | HELP FIGHT MS | $1,300 |
| THE JOURNEY CHURCH | |||||||
| 424 COLUMBUS AVENUE | EAST PATCHOGUE | NY | 11772 | NONE | CHURCH | ADOPT A FAMILY - HOLIDAY | $1,262 |
| CONNETQUOT YOUTH ASSOCIATION | |||||||
| 550 EASTON STREET | RONKONKOMA | NY | 11779 | NONE | NOT FOR P | SPECIAL NEEDS TBALL FIELD | $1,050 |
| EPILEPSY FOUNDATION OF NY | |||||||
| 506 STEWART AVENUE | GARDEN CITY | NY | 11530 | NONE | 501(c)(3) | CARING FOR PEOPLE IN NEED | $500 |
| PRONTO OF LI INC | |||||||
| 128 PINE AIRE DRIVE | BAY SHORE | NY | 11708 | NONE | PUBLIC SC | SCHOOL SUPPLIES | $551 |
| LAKELAND FIRE DEPARTMENT | |||||||
| 929 JOHNSON AVE | RONKONKOMA | NY | 11779 | NONE | NC | FIRE DEPARMENT CONTRIBUTION | $200 |
| THE GRETSUK FAMILY | |||||||
| 170 VICTORY DR | RONKONKOMA | NY | 11779 | NONE | I | BEDROOM SET | $1,090 |
| THE THOMAS MILOSCIA FAMILY | |||||||
| 2 HARRISON AVE | SETAUKET | NY | 11733 | NONE | I | UTILITY BILL | $2,408 |
| CHRISTINE DUBRITZ | |||||||
| 26 Niewood Drive | Ridge | NY | 11961 | NONE | I | UTILITY BILL | $508 |
| GAIL KELLAHER FAMILY | |||||||
| 35C Country Club Drive | Coram | NY | 11727 | NONE | I | FOOD | $599 |
| LEUKEMIA LYMPHOMA SOCIETY | |||||||
| 1324 Motor Parkway - SUITE 102 | Hauppauge | NY | 11749 | NONE | 501(c)(3) | CARING FOR PEOPLE IN NEED | $100 |
| PAUL MURAWSKI | |||||||
| 19 Cornella Lane | Lake Grove | NY | 11755 | NONE | I | UTILITY BILLS | $5,188 |
| JUSTINTIME GOLDEN HEART RANCH | |||||||
| 703 Pier Avenue | Hermosa Beach | CA | 90254 | NONE | 501(c)(3) | CARING FOR PEOPLE IN NEED | $200 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Grant Or Contri Pd Dur Yr | $14,956 | TotalGrantOrContriPdDurYrAmt |
Analysis Income Producing Acty AnalysisIncomeProducingActyGrp
Int On Sav And Temp Cash Invst IntOnSavAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Related Or Exempt Function Incm | $1 | RelatedOrExemptFunctionIncmAmt |
Subtotals Incm Producing Acty SubtotalsIncmProducingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Related Or Exempt Function Incm | $1 | RelatedOrExemptFunctionIncmAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Income Producing Acty | $1 | TotalIncomeProducingActyAmt |
Trnsfr Trans Rln Nonchrtbl EO TrnsfrTransRlnNonchrtblEOGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trnsfr Of Cash To Nonchrtbl EO | false | TrnsfrOfCashToNonchrtblEOInd |
| Trnsfr Other Asset Nonchrtbl EO | false | TrnsfrOtherAssetNonchrtblEOInd |
| Sales Or Exchanges Of Assets | false | SalesOrExchangesOfAssetsInd |
| Purchase Of Assets Nonchrtbl EO | false | PurchaseOfAssetsNonchrtblEOInd |
| Rental Of Facilities Oth Assets | false | RentalOfFacilitiesOthAssetsInd |
| Reimbursement Arrangements | false | ReimbursementArrangementsInd |
| Loans Or Loan Guarantees | false | LoansOrLoanGuaranteesInd |
| Performance Of Services Etc | false | PerformanceOfServicesEtcInd |
| Sharing Of Facilities Etc | false | SharingOfFacilitiesEtcInd |
| Relationships Nonchrtbl EO | false | RelationshipsNonchrtblEOInd |
Schedule B IRS990ScheduleB
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization501c3 Exempt PF | Yes (X) | Organization501c3ExemptPFInd |
| General Rule | Yes (X) | GeneralRuleInd |
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | 1 | ContributorNum |
| Contributor Person | JACK SEFERIAN | ContributorPersonNm |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 201 CANAL ROAD | AddressLine1Txt |
| City | PORTJEFFERSON STAT | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 11776 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | $20,500 | TotalContributionsAmt |
| Person Contribution | Yes (X) | PersonContributionInd |
Accounting Fees Schedule AccountingFeesSchedule
Accounting Fees Detail AccountingFeesDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Category | ACCOUNTING FEES | CategoryTxt |
| Amt | $500 | Amt |
| Net Investment Income | $0 | NetInvestmentIncomeAmt |
| Adjusted Net Income | $0 | AdjustedNetIncomeAmt |
| Disbursements Charitable Prps | $0 | DisbursementsCharitablePrpsAmt |
Other Expenses Schedule OtherExpensesSchedule
Other Expenses Schedule OtherExpensesScheduleGrp (6 entries)
| DescDesc | Revenue And Expenses Per BooksRevenueAndExpensesPerBooksAmt |
|---|---|
| Holiday Party | $1,444 |
| Insurance - Liability, D and O | $77 |
| Postage, Mailing Service | $664 |
| Supplies for events | $799 |
| Telephone, Telecommunications | $1,074 |
| Utilities | $2,969 |
Substantial Contributors Sch SubstantialContributorsSch
Substantial Contributor Detail SubstantialContributorDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | JACK SEFERIAN | PersonNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 201 CANAL ROAD | AddressLine1Txt |
| City | PORT JEFFERSON STAT | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 11776 | ZIPCd |