FORM 1023-EZ for UPPER ROOM YOUTH MINISTRIES

Field Data
EIN 83-2506019
Case Number EO-2018323-000558
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name UPPER ROOM YOUTH MINISTRIES
Organization’s Mailing Address 1195 SKYHAWK BLVD
City ANN ARBOR
State MI
ZIP 48103
Accounting period End 12
Primary contact name VICTOR N TEN BRINK
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

JONATHON MROCZKA
PRESIDENT/DIRECTOR
35823 PARKDALE ST
LIVONIA MI 48150

Officer/Director/Trustee Two

SAMUEL WENSLEY
DIRECTOR
46792 DOUBLETREE RD
CANTON MI 48187

Officer/Director/Trustee Three

CALEB GAGNON
DIRECTOR
1195 SKYHAWK BLVD
ANN ARBOR MI 48103

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 11/5/18
Organization Incorporation State MI
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code X20 - Christian
Organization’s purpose Charitable: No
Religious: Yes
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 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 JONATHON MROCZKA
Signature Title PRESIDENT/DIRECTOR
Signature Date 11/16/18

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