FORM 1023-EZ for HAITI SANS CERVICAL CANCER

Field Data
EIN 81-4860941
Case Number EO-2017032-000105
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name HAITI SANS CERVICAL CANCER
Organization’s Mailing Address 1921 NORTH POINTE DRIVE SUITE 200
City DURHAM
State NC
ZIP 27705
Accounting period End 12
Primary contact name DAVID K WALMER
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

DAVID K WALMER
MD, PHD
5908 HATHAWAY LANE
CHAPEL HILL NC 27514

Officer/Director/Trustee Two

CAROL F ROYE
RN
48 BROWNING DRIVE
OSSINING NY 10562-5102

Officer/Director/Trustee Three

LESLEE J JAEGER
MD
13015 44TH AVENUE NORTH
MINNEAPOLIS MN 55442

Officer/Director/Trustee Four

RACHEL MASCH
MD
25 BROADWAY
NEW YORK NY 10004

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 11/3/2015
Organization Incorporation State NC
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E32 - Ambulatory Health Center, Community Clinic
Organization’s purpose Charitable: Yes
Religious: No
Educational: Yes
Scientific: Yes
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 Yes
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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