FORM 1023-EZ for CASEY TOLLEFSON MEMORIAL FUND

Field Data
EIN 83-2387090
Case Number EO-2019064-000073
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name CASEY TOLLEFSON MEMORIAL FUND
Organization’s Mailing Address PO BOX 92
City HITCHCOCK
State SD
ZIP 57348-6812
Accounting period End 5
Primary contact name JACOB BOOMSMA
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

JACOB BOOMSMA
OFFICER
19105 MAPLE AVE
HITCHCOCK SD 57348-6812

Officer/Director/Trustee Two

KASSIE BOOMSMA
OFFICER
19105 MAPLE AVE
HITCHCOCK SD 57348-6812

Officer/Director/Trustee Three

ADAM BUSHFIELD
OFFICER
570 MAPLE AVE
HITCHCOCK SD 57348-6812

Organization’s website
Organization’s email JSBKJB@GMAIL.COM
Organization Incorporated No
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 10/31/18
Organization Incorporation State SD
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code S99 - Community Improvement, Capacity Building N.E.C.
Organization’s purpose Charitable: Yes
Religious: No
Educational: No
Scientific: No
Literary: No
Public Safety: No
Amateur Sports: No
Cruelty Prevention: No
Qualify For Exemption No
Legislation influence No
Compensation of Officer director trustee No
Donation of funds No
Conducting Activities Outside of United States No
Financial transactions with officers No
Unrelated Gross Income $1,000 or More No
Gaming Activity No
Disaster relief assistance No
One Third Support Public No
One Third Support Gifts No
Benefit of College No
Private Foundation 508(e) Yes
Seeking Retroactive Reinstatement No
Seeking Section 7 Reinstatement No
Correctness Declaration Yes
Signature Name JACOB BOOMSMA
Signature Title OFFICER
Signature Date 3/1/19

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