FORM 1023-EZ for BUSHIDO KAI AMERICA INC

Field Data
EIN 38-4103465
Case Number EO-2019136-000224
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name BUSHIDO KAI AMERICA INC
Organization’s Mailing Address 1234 N MAIN ST
City BOWLING GREEN
State OH
ZIP 43402
Accounting period End 12
Primary contact name JAMIE LIVERGOOD
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

JAMIE LIVERGOOD
PRESIDENT
541 NORTH ST
JEYY CITY OH 43437

Officer/Director/Trustee Two

MIKE DEMBICKI
VICE PRESIDENT
6095 LINWOOD RD
PEMBERVILLE OH 43450

Officer/Director/Trustee Three

ASHLEY SIEK
TREASURER
6436 MCCORMICK ST
WEST MILGROVE OH 43467

Officer/Director/Trustee Four

SCOTT KRIENBRINK
SECRETARY
1575 SOUTHRIDGE DR
WATERVILLE OH 43566

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 1/1/19
Organization Incorporation State OH
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code N60 - Amateur Sports Clubs, Leagues, N.E.C.
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 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 MIKE DEMBICKI
Signature Title VICE PRESIDENT
Signature Date 5/14/19

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