FORM 1023-EZ for BACK IN BLACK DOG RESCUE

Field Data
EIN 81-1620534
Case Number EO-2016347-000316
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name BACK IN BLACK DOG RESCUE
Organization’s Mailing Address 246 CLARKS VALLEY ROAD
City TOWER CITY
State PA
ZIP 17980
Accounting period End 12
Primary contact name CHIVON MURRAY
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

CHIVON MURRAY
PRESIDENT
246 CLARKS VALLEY ROAD
TOWER CITY PA 17980

Officer/Director/Trustee Two

DENISE KEIM
VICE PRESIDENT
254 CLARKS VALLEY ROAD
TOWER CITY PA 17980

Organization’s website WWW.BACKINBLACKRESQ.ORG
Organization’s email BACKINBLACKRESQ@YAHOO.COM
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 2/16/2016
Organization Incorporation State PA
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code D20 - Animal Protection and Welfare
Organization’s purpose Charitable: Yes
Religious: No
Educational: Yes
Scientific: No
Literary: No
Public Safety: No
Amateur Sports: No
Cruelty Prevention: Yes
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 Yes
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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