FORM 1023-EZ for MIKE BROCK MEMORIAL FUND

Field Data
EIN 82-2301461
Case Number EO-2017220-000224
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name MIKE BROCK MEMORIAL FUND
Organization’s Mailing Address 7465 COUNTY ROAD HH
City ARPIN
State WI
ZIP 54410
Accounting period End 12
Primary contact name TENA MANN
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

TENA MANN
OFFICER
7465 COUNTY ROAD HH
ARPIN WI 54410

Officer/Director/Trustee Two

SHANE LOVELAND
OFFICER
7454 STATE HIGHWAY 186
ARPIN WI 54410

Officer/Director/Trustee Three

NICHOLAS PANZER
OFFICER
3344 COUNTY ROAD N
MILLADORE WI 54454

Officer/Director/Trustee Four

CHRIS LABARGE
OFFICER
8465 COUNTY ROAD E
ARPIN WI 54410

Organization’s website
Organization’s email
Organization Incorporated No
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 5/8/2017
Organization Incorporation State WI
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code Z99 -
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 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
Signature Title
Signature Date

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