FORM 1023-EZ for CASA SAMUEL INC

Field Data
EIN 84-2800150
Case Number EO-2019289-000176
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name CASA SAMUEL INC
Organization’s Mailing Address 1000 WHITLOCK AVE PMB 157
City MARIETTA
State GA
ZIP 30064
Accounting period End 12
Primary contact name PAT MACPHERSON
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

PAT MACPHERSON
CHAIRMAN
761 HAMPTON PLACE
MARIETTA GA 30064

Officer/Director/Trustee Two

MARK HUMPHREY
TREASURER
1000 WHITLOCK AVE PMB 157
MARIETTA GA 30064

Officer/Director/Trustee Three

JUDITH EBERT
SECRETARY
1000 WHITLOCK AVE PMB 157
MARIETTA GA 30064

Officer/Director/Trustee Four

EVANGELINA ZAPATA NARVAEZ
DIRECTOR
1000 WHITLOCK AVE PMB 157
MARIETTA GA 30064

Officer/Director/Trustee Five

ROBERTO GARZA
DIRECTOR
1000 WHITLOCK AVE PMB 157
MARIETTA GA 30064

Organization’s website WWW.CASASAMUELUSA.COM
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 6/3/19
Organization Incorporation State GA
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code P11 - Single Organization Support
Organization’s purpose Charitable: Yes
Religious: No
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 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 JUDITH EBERT
Signature Title SECRETARY
Signature Date 10/14/19

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