FORM 1023-EZ for MOTHER NATURE CAMBODIA INC

Field Data
EIN 81-0694399
Case Number EO-2015341-000486
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name MOTHER NATURE CAMBODIA INC
Organization’s Mailing Address 7201 QUINCY AVENUE
City FALLS CHURCH
State VA
ZIP 22041
Accounting period End 12
Primary contact name ALEJANDRO GONZALEZ DAVIDSON
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

ALEJANDRO GONZALEZ DAVIDSON
PRESIDENT DIRECTOR
7201 QUINCY AVENUE
FALLS CHURCH VA 22041

Officer/Director/Trustee Two

MARCUS HARDTKE
SECRETARY DIRECTOR
205 N LAURA STREET
JACKSONVILLE FL 32202

Officer/Director/Trustee Three

KALYANEE MAM
TREASURER DIRECTOR
17470 OLD MONTE RIO ROAD
GUERNEVILLE CA 95446

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 11/25/2015
Organization Incorporation State FL
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code C30 - Natural Resources Conservation and Protection
Organization’s purpose Charitable: No
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 Yes
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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