FORM 1023-EZ for MENTAL HEALTH MATTERS COALITION

Field Data
EIN 83-2722414
Case Number EO-2020163-000285
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name MENTAL HEALTH MATTERS COALITION
Organization’s Mailing Address 626 MAIN STREET
City DARLINGTON
State WI
ZIP 53530
Accounting period End 12
Primary contact name SAMUEL FULLER
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

CANDI FITZSIMONS
PRESIDENT
626 MAIN STREET
DARLINGTON WI 53530

Officer/Director/Trustee Two

BRADLEY OSTBY
VICE PRESIDENT
626 MAIN STREET
DARLINGTON WI 53530

Officer/Director/Trustee Three

SAMUEL J FULLER
TREASURER
626 MAIN STREET
DARLINGTON WI 53530

Officer/Director/Trustee Four

LAURA HERMANSON
SECRETARY
626 MAIN STREET
DARLINGTON WI 53530

Organization’s website
Organization’s email SAMUEL.FULLER@LAFAYETTECOUNTYWI.ORG
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 12/5/2018
Organization Incorporation State WI
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code F80 - Mental Health Association, Multipurpose
Organization’s purpose Charitable: Yes
Religious: No
Educational: Yes
Scientific: No
Literary: No
Public Safety: No
Amateur Sports: No
Cruelty Prevention: Yes
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 SAMUEL J FULLER
Signature Title TREASURER
Signature Date 6/9/2020

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