FORM 1023-EZ for HAASE-LIEBERGESELL FAMILY FOUNDATION

Field Data
EIN 81-3136088
Case Number EO-2017191-000116
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name HAASE-LIEBERGESELL FAMILY FOUNDATION
Organization’s Mailing Address PO BOX 208
City VAUGHN
State WA
ZIP 98394
Accounting period End 12
Primary contact name JACOB L POTAK
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

SUSAN L BUNDA
DIRECTOR
16 ROOSEVELT AVE
LARCHMONT NY 10538

Officer/Director/Trustee Two

MANYA L ROSS
DIRECTOR
2219 WAVERLY
SEATTLE WA 98112

Officer/Director/Trustee Three

KATHY BAUER
DIRECTOR
7304 CRESCENT BEACH ROAD
VAUGHN WA 98394

Officer/Director/Trustee Four

SYLVIA A HAASE
DIRECTOR
PO BOX 208
VAUGHN WA 98394

Officer/Director/Trustee Five

VIRGINIA B LIEBERGESELL
DIRECTOR
PO BOX 208
VAUGHN WA 98394

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 6/27/2016
Organization Incorporation State WA
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code T22 - Private Independent Foundations
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 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
Signature Title
Signature Date

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