FORM 1023-EZ for COUNT ON ME INCORPORATION

Field Data
EIN 30-0611513
Case Number EO-2016081-000181
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name COUNT ON ME INCORPORATION
Organization’s Mailing Address 1024 WEST 600 NORTH
City SALT LAKE CITY
State UT
ZIP 84116
Accounting period End 12
Primary contact name DUANE A BURNETT
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

OKESENE MARINER
DIRECTOR
1024 WEST 600 NORTH
SALT LAKE CITY UT 84116

Officer/Director/Trustee Two

SAM MAAFALA
ASSISTANT DIRECTOR
1677 OXFORD STREET
SALT LAKE CITY UT 84117

Officer/Director/Trustee Three

JACKIE FIDOW
SECRETARY
1645 LINDEN LANE
BOUNTIFUL UT 84010

Officer/Director/Trustee Four

VILIAMU SEUMANU
CULTURE SPECIALIST
7836 SOUTH 2782 WEST
SOUTH JORDAN UT 84080

Officer/Director/Trustee Five

LUI FA
MUSIC ART CRAFTS
827 HEARST STREET
LAYTON UT 84041

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 1/24/2011
Organization Incorporation State UT
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code A20 - Arts, Cultural Organizations - Multipurpose
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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