FORM 1023-EZ for THE MSA SHOE INC

Field Data
EIN 47-2700163
Case Number EO-2015016-000533
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name THE MSA SHOE INC
Organization’s Mailing Address 29924 JEFFERSON AVENUE
City ST CLAIR SHORES
State MI
ZIP 48082-1843
Accounting period End 12
Primary contact name PHILIP M FORTIER
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

PHILIP M FORTIER
DIRECTOR AND PRESIDENT/CEO
29924 JEFFERSON AVENUE
ST CLAIR SHORES MI 48082-1843

Officer/Director/Trustee Two

CYNTHIA ROEMER
DIRECTOR AND TREASURER/CFO
29630 JEFFERSON AVENUE
ST CLAIR SHORES MI 48082-1827

Officer/Director/Trustee Three

PRATIK BHATTACHARYA
DIRECTOR AND SECRETARY
29924 JEFFERSON AVENUE
ST CLAIR SHORES MI 48082-1843

Organization’s website MSASHOE.ORG
Organization’s email MSASHOE@GMAIL.COM
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 12/30/2014
Organization Incorporation State MI
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code G80 - Specifically Named Diseases
Organization’s purpose Charitable: Yes
Religious: No
Educational: Yes
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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