FORM 1023-EZ for FUNCTIONAL MEDICINE OF THE RIO GRANDE

Field Data
EIN 82-5393152
Case Number EO-2018218-000298
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name FUNCTIONAL MEDICINE OF THE RIO GRANDE
Organization’s Mailing Address 1020 LAFAYETTE DR NE
City ALBUQUERQUE
State NM
ZIP 87106
Accounting period End 12
Primary contact name SEAN DIESEL
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

TIMOTHY DIESEL
DIRECTOR
1020 LAFAYETTE DR NE
ALBUQUERQUE NM 87106

Officer/Director/Trustee Two

ELIZABETH DIESEL
DIRECTOR
1020 LAFAYETTE DR NE
ALBUQUERQUE NM 87106

Officer/Director/Trustee Three

SEAN TUTEN
DIRECTOR
2712 MONK CT NW
ALBUQUERQUE NM 87107

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 3/13/18
Organization Incorporation State NM
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E32 - Ambulatory Health Center, Community Clinic
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 TIMOTHY DIESEL
Signature Title DIRECTOR
Signature Date 8/1/18

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