FORM 1023-EZ for A MODEL PATIENT
| Field | Data |
|---|---|
| EIN | 83-1050486 |
| Case Number | EO-2018232-000317 |
| Form 1023-EZ version | 12018 |
| Eligibility Worksheet | 1 |
| Organization Name | A MODEL PATIENT |
| Organization’s Mailing Address | 4219 SKILLMAN STREET |
| City | DALLAS |
| State | TX |
| ZIP | 75206 |
| Accounting period End | 12 |
| Primary contact name | DAK RASHETA |
| Primary contact phone | [Hidden] |
| Primary contact phone extension | [Hidden] |
| Primary contact fax | [Hidden] |
| User fee submitted | $275.00 |
Officer/Director/Trustee One
TARA RASHETA
OFFICER
4219 SKILLMAN STREET
DALLAS TX 75206
Officer/Director/Trustee Two
PETER DIRLIS
DIRECTOR
4516 LOVERS LANE APT 359
DALLAS TX 75225
Officer/Director/Trustee Three
ANISSA RASHETA
DIRECTOR
764 NORTH YORK CIRCLE
MESA AZ 85213
Officer/Director/Trustee Four
HALEY GRAY
DIRECTOR
3700 BRIAR OAK CIRCLE
MOUNTAIN BROOK AL 35223
| Organization’s website | |
|---|---|
| Organization’s email | |
| Organization Incorporated | Yes |
| Organization trust | No |
| Necessary Organizing Documents | Yes |
| Organization Incorporation Date | 5/18/18 |
| Organization Incorporation State | TX |
| Contains Limitation | Yes |
| Does not expressly empower | Yes |
| Contains dissolution | Yes |
| National Taxonomy of Exempt Entities (NTEE) code | G30 - Cancer |
| 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 | No |
| One Third Support Gifts | No |
| Benefit of College | No |
| Private Foundation 508(e) | Yes |
| Seeking Retroactive Reinstatement | No |
| Seeking Section 7 Reinstatement | No |
| Correctness Declaration | Yes |
| Signature Name | TARA RASHETA |
| Signature Title | OFFICER |
| Signature Date | 8/16/18 |
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