FORM 1023-EZ for THE BLUEH I V FOUNDATION

Field Data
EIN 82-2018181
Case Number EO-2017184-000197
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name THE BLUEH I V FOUNDATION
Organization’s Mailing Address 3208 GRANDEUR RD
City CHARLOTTE
State NC
ZIP 28269
Accounting period End 12
Primary contact name RITA RIDDICK SEALS
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

RITA SEALS
DIRECTOR
3208 GRANDEUR RD
CHARLOTTE NC 28269

Officer/Director/Trustee Two

RASHAWN FLOURNOY
DIRECTOR
528 NELSON AVE
CHARLOTTE NC 28262

Officer/Director/Trustee Three

JUSTIN FLORUNOY
DIRECTOR
2229 VILLAGE LAKE DR
CHARLOTTE NC 28216

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 6/2/2017
Organization Incorporation State NC
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E20 - Hospitals and Related Primary Medical Care Facilities
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 No
Benefit of College No
Private Foundation 508(e) Yes
Seeking Retroactive Reinstatement No
Seeking Section 7 Reinstatement No
Correctness Declaration Yes
Signature Name
Signature Title
Signature Date

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