FORM 1023-EZ for JEFFERSON COUNTY IMPACT 100

Field Data
EIN 46-2846635
Case Number EO-2015091-000175
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name JEFFERSON COUNTY IMPACT 100
Organization’s Mailing Address 364 SE WOODSIDE COURT
City MADRAS
State OR
ZIP 97741
Accounting period End 6
Primary contact name PALMER GROTE
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

PALMER GROTE
CO-FACILITATOR
496 NW IVY LANE
MADRAS OR 97741

Officer/Director/Trustee Two

CHRISTIE YOUNG
CO-FACILITATOR
66 NE A STREET
MADRAS OR 97741

Officer/Director/Trustee Three

SHARI DURGAN
CO-FACILITATOR
2071 SE MADRAS ROAD
MADRAS OR 97741

Officer/Director/Trustee Four

KAYLA WHITAKER
SECRETARY
152 SW CRESTVIEW LANE
MADRAS OR 97741

Officer/Director/Trustee Five

PATTY LIEUALLEN
TREASURER
364 SE WOODSIDE COURT
MADRAS OR 97741

Organization’s website
Organization’s email
Organization Incorporated No
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 6/6/2013
Organization Incorporation State OR
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code T12 - Fund Raising and/or Fund Distribution
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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