FORM 1023-EZ for AMERICAN DIAGNOSTIC AND WELLNESS INC

Field Data
EIN 81-2031601
Case Number EO-2016092-000381
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name AMERICAN DIAGNOSTIC AND WELLNESS INC
Organization’s Mailing Address 5256 S MISSION ROAD SUITE 703-202
City BONSALL
State CA
ZIP 92003
Accounting period End 12
Primary contact name ROBERT DUCK
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

ROBERT DUCK
PRESIDENT AND DIRECTOR
5256 S MISSION ROAD SUITE 703-202
BONSALL CA 92003

Officer/Director/Trustee Two

KATHY TEMPLE
DIRECTOR
32950 MAIDEN LANE
LAKE ELSINORE CA 92530

Officer/Director/Trustee Three

JON NORTHRUP
DIRECTOR
3413 PUNTA ALTA UNIT N
LAGUNA WOODS CA 92637

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 3/10/2015
Organization Incorporation State CA
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E21 - Community Health Systems
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 Yes
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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