FORM 1023-EZ for SURVIVORS INK

Field Data
EIN 47-4736721
Case Number EO-2015237-000111
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name SURVIVORS INK
Organization’s Mailing Address PO BOX 9184
City COLUMBUS
State OH
ZIP 43209
Accounting period End 12
Primary contact name MARY STICE
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

JENNIFER KEMPTON
CEO
PO BOX 9184
COLUMBUS OH 43209

Officer/Director/Trustee Two

MARY STICE
COO
3205 PARKSIDE RD
COLUMBUS OH 43204

Organization’s website WWW.SURVIVORSINK.ORG
Organization’s email JENNIFER@SURVIVORSINK.ORG
Organization Incorporated No
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 7/29/2015
Organization Incorporation State OH
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code P99 - Human Services - Multipurpose and Other N.E.C.
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 Yes
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 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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