FORM 1023-EZ for NORTHERN PLAINS RURAL SURGICAL SOCIETY

Field Data
EIN 81-4503823
Case Number EO-2016330-000382
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name NORTHERN PLAINS RURAL SURGICAL SOCIETY
Organization’s Mailing Address 1542 GOLF COURSE ROAD STE 202
City GRAND RAPIDS
State MN
ZIP 55744
Accounting period End 12
Primary contact name SHOLOM R BLAKE CPA
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

DANIEL J MARGO
PRESIDENT
1542 GOLF COURSE ROAD STE 202
GRAND RAPIDS MN 55744

Officer/Director/Trustee Two

MARK F DEATHERAGE
BOARD MEMBER
1542 GOLF COURSE ROAD STE 202
GRAND RAPIDS MN 55744

Officer/Director/Trustee Three

JOHN J RYAN
BOARD MEMBER
1542 GOLF COURSE ROAD STE 202
GRAND RAPIDS MN 55744

Officer/Director/Trustee Four

LUIS A GARCIA
BOARD MEMBER
1542 GOLF COURSE ROAD STE 202
GRAND RAPIDS MN 55744

Officer/Director/Trustee Five

SCOTT D CHARETTE
BOARD MEMBER
1542 GOLF COURSE ROAD STE 202
GRAND RAPIDS MN 55744

Organization’s website
Organization’s email
Organization Incorporated No
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 1/1/2016
Organization Incorporation State MN
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code B03 - Professional Societies, Associations
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 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 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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