FORM 1023-EZ for HOUSE OF MERCY BREATH OF LIFE INC

Field Data
EIN 82-1373361
Case Number EO-2017205-000362
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name HOUSE OF MERCY BREATH OF LIFE INC
Organization’s Mailing Address 103 24 ROOSEVELT AVENUE SUITE 203
City QUEENS
State NY
ZIP 11368
Accounting period End 12
Primary contact name HECTOR ANDERSON
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

VICTOR TIBURCIO
PRESIDENT
205 08 50TH AVENUE
OAKLNAD GARDENS NY 11364

Officer/Director/Trustee Two

HATTIE TIBURCIO
VICE PRESIDENT
205 08 50TH AVENUE
OAKLAND GARDENS NY 11364

Officer/Director/Trustee Three

KARI SAMANTHA VELEZ
SECRETARY
6030 BACARRA LANE 1G
RELEIGH NC 27606

Officer/Director/Trustee Four

JAIME TAMAY
BOARD MEMBER
8418 124TH STREET
NEW GARDENS NY 11415

Officer/Director/Trustee Five

RUTH SHEPARD
BOARD MEMBER
149 21 DELAWARE AVENUE
FLUSHING NY 11355

Organization’s website NONE
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 7/21/2017
Organization Incorporation State NY
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code X20 - Christian
Organization’s purpose Charitable: Yes
Religious: Yes
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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