FORM 1023-EZ for SERENITY RESIDENTIAL HOME INC

Field Data
EIN 81-1211650
Case Number EO-2016067-000223
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name SERENITY RESIDENTIAL HOME INC
Organization’s Mailing Address 4808 WATAUGA ROAD
City FAYETTEVILLE
State NC
ZIP 28304
Accounting period End 12
Primary contact name GLENDER PEE
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

THERESA HIGHSMITH
DIRECTOR
4808 WATAUGA
FAYETTEVILLE NC 28304

Officer/Director/Trustee Two

GWENDOLYN QUICK
BOARDMEMBER
2202 ROTHWOOD ACRES
GREENSBORO NC 27404

Officer/Director/Trustee Three

MARCUS RAYNOR
BOARDMEMBER
3202 SANDEROSA ROAD
FAYETTEVILLE NC 28302

Officer/Director/Trustee Four

MICHAEL RANDALL
BOARDMEMBER
115 SOUTHGATE BLVD
MCDONOUGH GA 30253

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 1/11/2016
Organization Incorporation State NC
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code X99 - Religion Related, Spiritual Development N.E.C.
Organization’s purpose Charitable: Yes
Religious: No
Educational: Yes
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 Yes
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 Yes
Correctness Declaration Yes
Signature Name
Signature Title
Signature Date

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