FORM 1023-EZ for LOCH HAVEN SENIOR LIVING COMMUNITYFOUNDATION

Field Data
EIN 81-1423657
Case Number EO-2019114-000308
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name LOCH HAVEN SENIOR LIVING COMMUNITYFOUNDATION
Organization’s Mailing Address 701 SUNSET HILLS DRIVE
City MACON
State MO
ZIP 63552
Accounting period End 6
Primary contact name KELSEY HINSHAW
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

RICHARD WALLER
MEMBER
32776 STATE HWY PP
MACON MO 63552

Officer/Director/Trustee Two

BARBARA ROBERTS
PRESIDENT
1202 WEST BOURKE
MACON MO 63552

Officer/Director/Trustee Three

KELSEY HINSHAW
SECRETARY
4289 SHELBY 343
SHELBYVILLE MO 63469

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 11/7/15
Organization Incorporation State MO
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code T20 - Private Grantmaking Foundations
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 Yes
Seeking Section 7 Reinstatement No
Correctness Declaration Yes
Signature Name KELSEY HINSHAW
Signature Title SECRETARY
Signature Date 4/22/19
EIN 81-1423657
Case Number EO-2016214-000289
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name LOCH HAVEN SENIOR LIVING COMMUNITYFOUNDATION INC
Organization’s Mailing Address 701 SUNSET HILLS DR
City MACON
State MO
ZIP 63552
Accounting period End 6
Primary contact name MARY BETH TRUITT
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

KAY FREEMAN
PRESIDENT
29778 FIREWORKS AVE
CALLAO MO 63534

Officer/Director/Trustee Two

KELSEY HINSHAW
TREASURER
5416 SHELBY 3351
SHELBINA MO 63468

Officer/Director/Trustee Three

RICHARD WALLER 32776
MEMBER
32776 STATE HWY PP
MACON MO 63552

Officer/Director/Trustee Four

MARY BETH TRUITT
DIRECTOR
1006 SUNSET DR
MACON MO 63552

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 11/7/2015
Organization Incorporation State MO
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E11 - Single Organization Support
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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