FORM 1023-EZ for FREE CLINIC CORPORATION

Field Data
EIN 81-3602101
Case Number EO-2017227-000139
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name FREE CLINIC CORPORATION
Organization’s Mailing Address PO BOX 772291
City MIAMI
State FL
ZIP 33177
Accounting period End 12
Primary contact name DAPHNE MATHURIN
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

DOMINIC RIVERA
PRESIDENT
9130 SW 166TH PL
TAMPA FL 33196

Officer/Director/Trustee Two

JEAN-MARC LAHENS
VICE PRESIDENT
PO BOX 772291
MIAMI FL 33177

Officer/Director/Trustee Three

TAMAH MATHURIN
SECRETARY
PO BOX 772291
MIAMI FL 33177

Officer/Director/Trustee Four

MILDRED MALVAL
TREASURER
PO BOX 772291
MIAMI FL 33177

Organization’s website THEFREECLINICPROJECT.NET
Organization’s email FREECLINICCORP@GMAIL.COM
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 7/18/2016
Organization Incorporation State FL
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code T50 - Philanthropy, Charity, Voluntarism Promotion, General
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 Yes
Financial transactions with officers No
Unrelated Gross Income $1,000 or More No
Gaming Activity No
Disaster relief assistance Yes
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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