FORM 1023-EZ for USA ROLLER DERBY

Field Data
EIN 82-3077745
Case Number EO-2018065-000415
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name USA ROLLER DERBY
Organization’s Mailing Address 5803 SE 84TH AVE
City PORTLAND
State OR
ZIP 97266
Accounting period End 12
Primary contact name JULIANA GONZALES
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

JULIANA GONZALES
CHAIR
1402 SANCHEZ ST
AUSTIN TX 78702

Officer/Director/Trustee Two

BERNARDO JUSTIN CAMPOY
VICE CHAIR
48-16 46TH ST D5
WOODSIDE NY 11377

Officer/Director/Trustee Three

NICOLE WILLIAMS
SECRETARY AND TREASURER
5803 SE 84TH AVE
PORTLAND OR 97266

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 10/12/17
Organization Incorporation State OR
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code N71 - Olympics Committees and Related International Competitions
Organization’s purpose Charitable: Yes
Religious: No
Educational: No
Scientific: No
Literary: No
Public Safety: No
Amateur Sports: Yes
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 JULIANA GONZALES
Signature Title CHAIR
Signature Date 3/4/18

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