FORM 1023-EZ for AJNA COMMUNITY HEALTH

Field Data
EIN 83-1473286
Case Number EO-2018247-000650
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name AJNA COMMUNITY HEALTH
Organization’s Mailing Address 1409 NW 85TH ST
City SEATTLE
State WA
ZIP 98117
Accounting period End 12
Primary contact name DIANA DERICKS
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

DIANA DERICKS
DIRECTOR, PRESIDENT
1409 NW 85TH ST
SEATTLE WA 98117

Officer/Director/Trustee Two

EMILY PASSIC
DIRECTOR
1409 NW 85TH ST
SEATTLE WA 98117

Officer/Director/Trustee Three

ANNA GRAKLANOFF
DIRECTOR
1409 NW 85TH ST
SEATTLE WA 98117

Officer/Director/Trustee Four

MICHAEL WEINERT
SECRETARY/TREASURER
1409 NW 85TH ST
SEATTLE WA 98117

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 7/16/18
Organization Incorporation State WA
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E70 - Public Health Program (Includes General Health and Wellness Promotion Services)
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 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 DIANA DERICKS
Signature Title DIRECTOR, PRESIDENT
Signature Date 8/31/18

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