FORM 1023-EZ for HEALTHY COMMUNITIES A3

Field Data
EIN 46-4631748
Case Number EO-2015036-000264
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name HEALTHY COMMUNITIES A3
Organization’s Mailing Address PO BOX 297
City ASHEBORO
State NC
ZIP 27204-0297
Accounting period End 12
Primary contact name RAEFORD WENDELL HOLLAND JR
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

RAEFORD WENDELL HOLLAND JR
CHAIRPERSON
1519 SHAMROCK ROAD
ASHEBORO NC 27205-7060

Officer/Director/Trustee Two

SAMUEL ANDREW VARNER
VICE CHAIRPERON
1047 N ROCK RIDGE RD
ASHEBORO NC 27205-4138

Officer/Director/Trustee Three

MART DAVID FOWLER
TREASURER
1950 BERKLEY PL
ASHEBORO NC 27205-4179

Officer/Director/Trustee Four

LISA JONES PARK
SECRETARY
2882 OLD LEXINGTON RD
ASHEBORO NC 27205-2557

Officer/Director/Trustee Five

JAMES MCGAUHEY RICH
DIRECTOR
1167 WESTOVER TER
ASHEBORO NC 27205-4156

Organization’s website HEALTHYCOMMUNITIESA3
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 9/9/2014
Organization Incorporation State NC
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E70 - Public Health Program (Includes General Health and Wellness Promotion Services)
Organization’s purpose Charitable: No
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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