FORM 1023-EZ for THE BLACK LOTUS FOUNDATION

Field Data
EIN 47-3547086
Case Number EO-2015105-000256
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name THE BLACK LOTUS FOUNDATION
Organization’s Mailing Address 14100 CEDAR ROAD SUITE 160
City UNIVERSITY HEIGHTS
State OH
ZIP 44121
Accounting period End 12
Primary contact name MATTHEW ROSSMAN
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

JAVONE WILLIAMS
CHAIRMAN DIRECTOR
1522 E 250TH ST
EUCLID OH 44117

Officer/Director/Trustee Two

STEVE HALTON
DIRECTOR
2082 NEWCOME ST
RICHMOND HEIGHTS OH 44143

Officer/Director/Trustee Three

STEVE HARRIS
TREASURER DIRECTOR
11801 DOVE AVE
CLEVELAND OH 44105

Officer/Director/Trustee Four

TIFFANY HILL
VICE PRESIDENT DIRECTOR
14505 WHEELER RD
MAPLE HEIGHTS OH 44121

Officer/Director/Trustee Five

MARC WILSON
PRESIDENT DIRECTOR
14100 CEDAR ROAD SUITE 160
UNIVERSITY HEIGHTS OH 44121

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 2/5/2015
Organization Incorporation State OH
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code O50 - Youth Development Programs, Other
Organization’s purpose Charitable: Yes
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 Yes
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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