FORM 1023-EZ for CLINICIAN REFERRAL COLLECTIVE

Field Data
EIN 83-0773356
Case Number EO-2018158-000176
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name CLINICIAN REFERRAL COLLECTIVE
Organization’s Mailing Address 3718 SW CORBETT AVE
City PORTLAND
State OR
ZIP 97239
Accounting period End 12
Primary contact name KYIRSTY UNGER
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

PAUL UNGER
DIRECTOR
5648 N PEPPARD AVE
MERIDIAN ID 83646

Officer/Director/Trustee Two

JAMIE AQUINO
DIRECTOR
8864 SW ASH MEADOWS CIR
WILSONVILLE OR 97070

Officer/Director/Trustee Three

MAIYAN LIANE
DIRECTOR
4680 W JEWELL ST
BOISE ID 83706

Organization’s website
Organization’s email
Organization Incorporated No
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 6/5/18
Organization Incorporation State OR
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E60 - Health Support Services
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 Yes
Benefit of College No
Private Foundation 508(e) No
Seeking Retroactive Reinstatement No
Seeking Section 7 Reinstatement No
Correctness Declaration Yes
Signature Name PAUL UNGER
Signature Title DIRECTOR
Signature Date 6/5/18

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