FORM 1023-EZ for MOUNTAIN BREEZE ANIMAL REFUGE

Field Data
EIN 86-3915499
Case Number EO-2021141-000548
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name MOUNTAIN BREEZE ANIMAL REFUGE
Organization’s Mailing Address 760 CIRCLE DR
City LEBEC
State CA
ZIP 93243
Accounting period End 12
Primary contact name HENRY KJELLANDER CPA EA
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

STEPHAN KIOUSES
DIRECTOR
760 CIRCLE DR
LEBEC CA 93243

Officer/Director/Trustee Two

DENA KIOUSES
DIRECTOR
760 CIRCLE DR
LEBEC CA 93243

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 1/26/2021
Organization Incorporation State CA
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code D20 - Animal Protection and Welfare
Organization’s purpose Charitable: Yes
Religious: No
Educational: No
Scientific: No
Literary: No
Public Safety: No
Amateur Sports: No
Cruelty Prevention: Yes
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 Yes
Benefit of College No
Private Foundation 508(e) No
Seeking Retroactive Reinstatement No
Seeking Section 7 Reinstatement No
Correctness Declaration Yes
Signature Name STEPHAN KIOUSES
Signature Title DIRECTOR
Signature Date 5/18/2021

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