FORM 1023-EZ for TRI-VALLEY YOUTH SOCCER ASSOCIATION

Field Data
EIN 10-0635543
Case Number EO-2016067-000172
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name TRI-VALLEY YOUTH SOCCER ASSOCIATION
Organization’s Mailing Address 11 DEEP CREEK ROAD
City HEGINS
State PA
ZIP 17938
Accounting period End 12
Primary contact name KIMBERLY ROTHERMEL
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

DAVE MILLER
PRESIDENT
632 CHURCH ROAD
HEGINS PA 17938

Officer/Director/Trustee Two

SCOTT BALLAY
VICE PRESIDENT
44 SPUN LANE
SACRAMENTO PA 17967

Officer/Director/Trustee Three

CHRISTINE WIEST
TREASURER
188 EAST MOUNTAIN ROAD
HEGINS PA 17938

Officer/Director/Trustee Four

KIM ROTHERMEL
REGISTRAR
11 DEEP CREEK ROAD
HEGINS PA 17938

Organization’s website
Organization’s email
Organization Incorporated No
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 1/1/2000
Organization Incorporation State PA
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code N64 - Soccer Clubs, Leagues
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
Signature Title
Signature Date

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