FORM 1023-EZ for THE LAVENDER CLINIC

Field Data
EIN 46-5731199
Case Number EO-2014282-000323
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name THE LAVENDER CLINIC
Organization’s Mailing Address 3221 WAIALAE AVENUE SUITE 360
City HONOLULU
State HI
ZIP 96816
Accounting period End 12
Primary contact name SAMUEL HAWK
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

SAMUEL HAWK
CEO, CHAIRMAN, ORGANIZER
848A KUNAWAI LANE
HONOLULU HI 96817

Officer/Director/Trustee Two

DAWN OGDEN
BOARD MEMBER
848A KUNAWAI LANE
HONOLULU HI 96817

Officer/Director/Trustee Three

GLENNIS PILGRAM
BOARD MEMBER
14326 ROCHESTER STREET NE
HAM LAKE MN 55304

Organization’s website WWW.LAVENDERCLINICHAWAII.COM
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 7/15/2014
Organization Incorporation State HI
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E30 - Health Treatment Facilities, Primarily Outpatient
Organization’s purpose Charitable: Yes
Religious: No
Educational: Yes
Scientific: Yes
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 Yes
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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