FORM 1023-EZ for UNITED CHURCH OF CHRIST MENTAL HEALTH NETWORK

Field Data
EIN 81-0710382
Case Number EO-2015338-000345
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name UNITED CHURCH OF CHRIST MENTAL HEALTH NETWORK
Organization’s Mailing Address 495 ONEIDA STREET
City BOULDER
State CO
ZIP 80303
Accounting period End 12
Primary contact name R JEFFREY POLLOCK
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

R ALAN JOHNSON
DIRECTOR, CHAIR AND PRESIDENT
495 ONEIDA STREET
BOULDER CO 80303

Officer/Director/Trustee Two

HANNAH CAMPBELL GUSTAFSON
DIRECTOR AND TREASURER
209 MAIN STREET
DARLINGTON WI 53530

Officer/Director/Trustee Three

SARAH GRIFFITH LUND
DIRECTOR AND VICE CHAIR
6536 FERGUSON STREET UNIT C
INDIANAPOLIS IN 46220

Officer/Director/Trustee Four

ROBIN KEMPSTER
DIRECTOR AND SECRETARY
983 PERALTA AVENUE
ALBANY CA 94706

Officer/Director/Trustee Five

R JEFFREY POLLOCK
DIRECTOR
600 SUPERIOR AVENUE E SUITE 2100
CLEVELAND OH 44114

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 8/20/2015
Organization Incorporation State OH
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code F01 - Alliance/Advocacy Organizations
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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