FORM 1023-EZ for K SAM ESSILFIE MEDICAL FOUNDATION

Field Data
EIN 10-0929549
Case Number EO-2016214-000298
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name K SAM ESSILFIE MEDICAL FOUNDATION
Organization’s Mailing Address P O BOX 11864
City SAN BERNARDINO
State CA
ZIP 92423
Accounting period End 12
Primary contact name PATRICIA ESSILFIE
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

PATRICIA ESSILFIE
OFFICER
P O BOX 11864
SAN BERNARDINO CA 92423

Officer/Director/Trustee Two

JOHN DADZIE
OFFICER
1132 WEST 124TH STREET
LOS ANGELES CA 90044

Officer/Director/Trustee Three

RENATA AHEGBEBU
OFFICER
8338 WOODLEY PL APT 48
NORTH HILLS CA 91343

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 12/9/2009
Organization Incorporation State CA
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code P20 - Human Service Organizations - Multipurpose
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 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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