FORM 1023-EZ for TAKE A BREAK RESPITE FOUNDATION INC

Field Data
EIN 82-1886978
Case Number EO-2017177-000309
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name TAKE A BREAK RESPITE FOUNDATION INC
Organization’s Mailing Address 781 EAST NORTHCLIFFE DRIVE
City SALT LAKE CITY
State UT
ZIP 84103
Accounting period End 12
Primary contact name LYNDA SMITH
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

LYNDA KATHRYN SMITH
DIRECTOR/CHAIR
781 E NORTHCLIFFE DRIVE
SALT LAKE CITY UT 84103

Officer/Director/Trustee Two

CARRIE CARTER
DIRECTOR/VICE CHAIR
6140 SHIRL STREET
SALT LAKE CITY UT 84123

Officer/Director/Trustee Three

JADE HANSEN PORTER
DIRECTOR/SECRETARY
2056 HAZELWOOD WAY
COTTONWOOD HEIGHTS UT 84121

Officer/Director/Trustee Four

MEAGAN JENSEN
DIRECTOR/TREASURER
7052 S CHERRY LEAF DRIVE
SOUTH JORDAN UT 84084

Officer/Director/Trustee Five

GINA MONEY
DIRECTOR/VICE CHAIR
1168 MARCO POLO LANE
SOUTH JORDAN UT 84095

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 6/16/2017
Organization Incorporation State UT
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E60 - Health Support Services
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 Yes
One Third Support Gifts No
Benefit of College No
Private Foundation 508(e) No
Seeking Retroactive Reinstatement No
Seeking Section 7 Reinstatement No
Correctness Declaration Yes
Signature Name
Signature Title
Signature Date

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