FORM 1023-EZ for UPPER ROOM DINING HALL INC

Field Data
EIN 47-4732040
Case Number EO-2017313-000177
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name UPPER ROOM DINING HALL INC
Organization’s Mailing Address P O BOX 484
City PLACERVILLE
State CA
ZIP 95667
Accounting period End 6
Primary contact name PAUL SAINDON
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

LINDA DELREAL
CHAIRMAN BOARD OF DIRECTORS
4501 BARNHOUSE ROAD
RESCUE CA 95672

Officer/Director/Trustee Two

COLETTE POLASKI
VICE CHAIRMAN
2050 RIBIER WAY
CAMERON PARK CA 95682

Officer/Director/Trustee Three

PAUL SAINDON
TREASURER
4390 PATTERSON DRIVE UNIT 293
DIAMOND SPRINGS CA 95619

Officer/Director/Trustee Four

LUCILLE KATAVICH
SECRETARY
5024QUAIL VALLEY ROAD
PLACERVILLE CA 95667

Officer/Director/Trustee Five

GENE HAYDU
DIRECTOR
4286ESTRLLITA COURT
SHINGLE SPRINGS CA 95682

Organization’s website WWW.UPPERROOMDININGHALL.ORG
Organization’s email TREASURER@UPPERROOMDININGHALL.ORG
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 7/9/2015
Organization Incorporation State CA
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code K30 - Food Service, Free Food Distribution Programs
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 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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