FORM 1023-EZ for IMPACT 29 11

Field Data
EIN 82-1602933
Case Number EO-2017144-000275
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name IMPACT 29 11
Organization’s Mailing Address 23511 SONOMA VALLEY DR
City MAGNOLIA
State TX
ZIP 77355
Accounting period End 12
Primary contact name LAUREN BORTNEM
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

LAUREN BORTNEM
PRESIDENT
23511 SONOMA VALLEY DR
MAGNOLIA TX 77355

Officer/Director/Trustee Two

COLLEEN MALCOLM
DIRECTOR
11315 WATER OAK LN
CYPRESS TX 77429

Officer/Director/Trustee Three

BRETT BORTNEM
DIRECTOR
23511 SONOMA VALLEY DR
MAGNOLIA TX 77355

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 4/1/2017
Organization Incorporation State TX
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code B01 - Alliance/Advocacy Organizations
Organization’s purpose Charitable: Yes
Religious: Yes
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 Yes
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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