FORM 1023-EZ for FAIRFIELD MEDICAL CENTER TWIG 17

Field Data
EIN 31-0934104
Case Number EO-2014338-000236
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name FAIRFIELD MEDICAL CENTER TWIG 17
Organization’s Mailing Address 401 N EWING STREET
City LANCASTER
State OH
ZIP 43130
Accounting period End 12
Primary contact name PENNY SCHWICKERATH ACCOUNTING
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

JANIE NICOLIA
PRESIDENT
140 W HIGH ST
AMANDA OH 43102

Officer/Director/Trustee Two

TAMMY VANSCOY
SECRETARY
2445 COLS-LANCASTER RD
LANCASTER OH 43130

Officer/Director/Trustee Three

CINDY SILCOTT
TREASURER
2478 COUNTY LINE ROAD
RUSHVILLE OH 43150

Organization’s website
Organization’s email
Organization Incorporated No
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 3/4/2010
Organization Incorporation State OH
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E12 - Fund Raising and/or Fund Distribution
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 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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