FORM 1023-EZ for PACIFIC ISLANDS SAFETY NETWORK

Field Data
EIN 66-0923777
Case Number EO-2019142-000373
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name PACIFIC ISLANDS SAFETY NETWORK
Organization’s Mailing Address PO BOX 2350
City PAGO PAGO
State AS
ZIP 96799
Accounting period End 12
Primary contact name MATAITUSI MARSHALL
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

MATAITUSI MARSHALL
PRESIDENT
PO BOX 2350
PAGO PAGO AS 96799

Officer/Director/Trustee Two

FAAFEO LAGAFUAINA
SECRETARY
PO BOX 2338
PAGO PAGO AS 96799

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 5/20/19
Organization Incorporation State AS
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code M40 - Safety Education
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 Yes
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 MATAITUSI MARSHALL
Signature Title PRESIDENT
Signature Date 5/20/19

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