FORM 1023-EZ for AMENA MOBILE CLINIC

Field Data
EIN 85-1380339
Case Number EO-2020224-000519
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name AMENA MOBILE CLINIC
Organization’s Mailing Address 14642 NEWPORT AVENUE / SUITE 110
City TUSTIN
State CA
ZIP 92780
Accounting period End 12
Primary contact name MASOUD NASSIMI
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

NAFISA NASSIMI ENTEZAR
PRESIDENT
23231 CASTLE ROCK
MISSION VIEJO CA 92692

Officer/Director/Trustee Two

MASOUD NASSIMI
VICE PRESIDENT
8675 BROOKE AVENUE
WESTMINSTER CA 92683

Officer/Director/Trustee Three

RASHID BASHIR
TREASURER
1401 WATERFORD PLACE
CHAMPAIGN IL 61821

Officer/Director/Trustee Four

NADIA IBRAHIM
SECRETARY
162 CALLE DE LOS NINOS
R. SANTA MARGARITA CA 92688

Organization’s website HTTPS://WWW.AMENAMOBILECLINIC.COM/
Organization’s email AMENAMOBILECLINIC@GMAIL.COM
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 6/6/2020
Organization Incorporation State CA
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E32 - Ambulatory Health Center, Community Clinic
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 Yes
One Third Support Public No
One Third Support Gifts Yes
Benefit of College No
Private Foundation 508(e) No
Seeking Retroactive Reinstatement No
Seeking Section 7 Reinstatement No
Correctness Declaration Yes
Signature Name MASOUD NASSIMI
Signature Title VICE PRESIDENT
Signature Date 8/7/2020

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