FORM 1023-EZ for JEWELL COUNTY WELLNESS INC

Field Data
EIN 82-1148612
Case Number EO-2017107-000109
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name JEWELL COUNTY WELLNESS INC
Organization’s Mailing Address PO BOX 54
City MANKATO
State KS
ZIP 66956
Accounting period End 12
Primary contact name EMMA MENHUSEN
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

LISA GOODHEART
DIRECTOR
230 HWY 128
GLEN ELDER KS 67446

Officer/Director/Trustee Two

BRIAN SHULDA
DIRECTOR
1645 150 RD
MANKATO KS 66956

Officer/Director/Trustee Three

SUSAN FLINN
DIRECTOR
101 VINE STREET
JEWELL KS 66949

Officer/Director/Trustee Four

ERIC BOURBON
DIRECTOR
864 HWY 14
JEWELL KS 66949

Officer/Director/Trustee Five

KRISTIN UNDERWOOD
DIRECTOR
890 R ROAD
MANKATO KS 66956

Organization’s website
Organization’s email
Organization Incorporated No
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 4/13/2017
Organization Incorporation State KS
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code S32 - Rural Development
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
Signature Title
Signature Date

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