FORM 1023-EZ for HARTLEYS SAFE HOUSE

Field Data
EIN 47-2112250
Case Number EO-2014314-000230
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name HARTLEYS SAFE HOUSE
Organization’s Mailing Address 14766 84TH ST NE
City OTSEGO
State MN
ZIP 55330
Accounting period End 12
Primary contact name MELANIE GRAY
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

RICHARD LINDSKOOG
PRESIDENT/CHAIR
14609 QUICKSILVER
RAMSEY MN 55303

Officer/Director/Trustee Two

ROBERT ELSTAD
BOARD MEMBER
18367 EVERGLADE DRIVE NE
WYOMING MN 55092

Officer/Director/Trustee Three

WENDY HARTLEY
BOARD MEMBER
21648 EAST BETHEL BLVD
EAST BETHEL MN 55011

Officer/Director/Trustee Four

PATRICIA HOFFSTROM
TREASURER
206 CEDAR RD
WYOMING MN 55092

Officer/Director/Trustee Five

MELANIE GRAY
INCORPORATOR
14766 84th st ne
otsego MN 55330

Organization’s website
Organization’s email HARTLEYSSAFEHOUSE@GMAIL.COM
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 11/3/2014
Organization Incorporation State MN
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code P43 - Family Violence Shelters, Services
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 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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