FORM 1023-EZ for THE HAVEN AT STAR LAKE

Field Data
EIN 46-3127173
Case Number EO-2015049-000199
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name THE HAVEN AT STAR LAKE
Organization’s Mailing Address 60 CAMPUS DRIVE
City STAR LAKE
State NY
ZIP 13690
Accounting period End 12
Primary contact name THOMAS BUCKINGHAM
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

THOMAS BUCKINGHAM
CHIEF EXECUTIVE OFFICER
12 D PINE STREET
STAR LAKE NY 13690

Officer/Director/Trustee Two

MARIA BUCKINGHAM
FINANCIAL OFFICER
12 D PINE STREET
STAR LAKE NY 13690

Officer/Director/Trustee Three

MARY MAUREEN SHANKLIN
CHAIRMAN, BOARD OF DIRECTORS
2759 MELROSE AVE
WOODSTOCK MD 21163

Officer/Director/Trustee Four

KAREN KUHN
OPERATIONS MANAGER BOD MEMBER
60 CAMPUS DR
STAR LAKE NY 13690

Officer/Director/Trustee Five

TERESA VON RIEGEN
DIRECTOR OF MARKETING BOD MEMBER
60 CAMPUS DR
STAR LAKE NY 13690

Organization’s website HTTP://HAVENSL.COM/
Organization’s email INFO@HAVENSL.COM
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 7/1/2013
Organization Incorporation State NY
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code N20 - Recreational and Sporting Camps
Organization’s purpose Charitable: Yes
Religious: Yes
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 Yes
Unrelated Gross Income $1,000 or More Yes
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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