FORM 1023-EZ for BLOOMIN BOUTIQUE

Field Data
EIN 83-2157929
Case Number EO-2018302-000334
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name BLOOMIN BOUTIQUE
Organization’s Mailing Address 19376 MOLALLA AVE STE 160
City OREGON CITY
State OR
ZIP 97045-9825
Accounting period End 9
Primary contact name WILLIAM J STALNAKER POA
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

PATRICIA SERRES
PRESIDENT / DIRECTOR
14620 S FORSYTHE RD
OREGON CITY OR 97045-9497

Officer/Director/Trustee Two

KARRIE AUSTIN
SECRETARY/TREASURER/DIRECTOR
903 JACKSON ST
OREGON CITY OR 97045-2062

Officer/Director/Trustee Three

BRIAN ALLEN
DIRECTOR
15680 S OUTLOOK TERRACE
OREGON CITY OR 97045-9251

Officer/Director/Trustee Four

JOANNE HAZEL
DIRECTOR
2415 BELLEVUE TERRACE
WEST LINN OR 97068-2294

Officer/Director/Trustee Five

CRAIG KLEIN
DIRECTOR
11670 SW SETTLER WAY
BEAVERTON OR 97008-7927

Organization’s website N/A
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 10/18/18
Organization Incorporation State OR
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code P60 - Emergency Assistance (Food, Clothing, Cash)
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 PATRICIA SERRES
Signature Title PRESIDENT / DIRECTOR
Signature Date 10/25/18

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