FORM 1023-EZ for PACIFIC HEALTH NETWORK INC

Field Data
EIN 83-2008944
Case Number EO-2019053-000023
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name PACIFIC HEALTH NETWORK INC
Organization’s Mailing Address 930 WAINEE STREET SUITE 9
City LAHAINA
State HI
ZIP 96761
Accounting period End 12
Primary contact name JUSTIN HAYS
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

DON PRESTAGE
CEO/DIRECTOR
910 HONOAPIILANI HWY UNIT 7-204
LAHAINA HI 96761

Officer/Director/Trustee Two

JUSTIN HAYS
TREASURER/DIRECTOR
930 WAINEE STREET SUITE 9
LAHAINA HI 96761

Officer/Director/Trustee Three

STUART KAHAN
SECRETARY/DIRECTOR
1028 WAINEE ST SUITE E-5
LAHAINA HI 96761

Organization’s website
Organization’s email JUSTIN_HAYS@HOTMAIL.COM
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 10/4/18
Organization Incorporation State HI
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code P99 - Human Services - Multipurpose and Other N.E.C.
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 Yes
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 JUSTIN HAYS
Signature Title TREASURER/DIRECTOR
Signature Date 2/20/19

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