FORM 1023-EZ for HOMER COMMUNITY FREE CLINIC

Field Data
EIN 47-3972259
Case Number EO-2015134-000265
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name HOMER COMMUNITY FREE CLINIC
Organization’s Mailing Address 178 E BUNNELL AVE
City HOMER
State AK
ZIP 99603
Accounting period End 12
Primary contact name LISA M ZATZ
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

LISA M ZATZ
PRESIDENT
178 E BUNNELL AVE
HOMER AK 99603

Officer/Director/Trustee Two

DANIEL ZATZ
VICE PRESIDENT, TREASURER
178 E BUNNELL AVE
HOMER AK 99603

Officer/Director/Trustee Three

SANDY CRONLAND
SECRETARY
65195 NEARLY LEVEL RD
HOMER AK 99603

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 5/11/2015
Organization Incorporation State AK
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E80 - Health, General and Financing
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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