FORM 1023-EZ for HEALTHY AMERICA INITIATIVE

Field Data
EIN 47-2427311
Case Number EO-2016159-000074
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name HEALTHY AMERICA INITIATIVE
Organization’s Mailing Address 253 ROCKFORD ROAD
City KERNERSVILLE
State NC
ZIP 27284
Accounting period End 12
Primary contact name VERNON WILLIAMS
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

VERNON WILLIAMS
CHIEF EXECUTIVE OFFICER
4203 HEWITT STREET 20-L
GREENSBORO NC 27406

Officer/Director/Trustee Two

FRAN CHARLTON
CHIEF FINANCIAL OFFICER
199 LARCH LANE
GREENSBORO NC 27406

Officer/Director/Trustee Three

RAYMOND TRAPP
CHIEF OPERATION OFFICER
3102 GOODALL DRIVE
GREENSBORO NC 27407

Officer/Director/Trustee Four

TAKIA STARKES
CHIEF MEDICAL OFFICER
4726 BYERS RIDGE DRIVE
GREENSBORO NC 27405

Officer/Director/Trustee Five

JUSTIN WASHINGTON
CHAIRMAN OF THE BOARD
1814 ACORN ROAD
GREENSBORO NC 27406

Organization’s website WWW.HEALTHYAMERICAINITIATIVE.ORG
Organization’s email VWILLIAMS@HEALTHYAMERICAINITIATIVE.ORG
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 11/14/2014
Organization Incorporation State NC
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E70 - Public Health Program (Includes General Health and Wellness Promotion Services)
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
Signature Title
Signature Date

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