FORM 1023-EZ for AGAPE SAFE HAVEN INC

Field Data
EIN 84-2992499
Case Number EO-2019273-000339
Form 1023-EZ version 12018
Eligibility Worksheet 1
Organization Name AGAPE SAFE HAVEN INC
Organization’s Mailing Address 43238 YALE COURT
City LANCASTER
State CA
ZIP 93536
Accounting period End 12
Primary contact name CAMILLE DYER
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

CAMILLE DYER
PRESIDENT
43238 YALE COURT
LANCASTER CA 93536

Officer/Director/Trustee Two

PORSHA BLAKE
VICE PRESIDENT
5516 S REDCLIFF DR UNIT A
TAYLORSVILLE UT 84123

Officer/Director/Trustee Three

DESHAWNA TRAVILLION
TREASURE
1043 S KINGSLEY DR UNIT 26
LOS ANGELES CA 90006

Officer/Director/Trustee Four

DESTINY WALKER
SECRETARY
1621 CACTUS DR UNIT C
LANCASTER CA 93535

Officer/Director/Trustee Five

CASSANDRA REED
MEMBER
8715 S 5TH AVENUE
INGLEWOOD CA 90305

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 8/13/19
Organization Incorporation State CA
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code X20 - Christian
Organization’s purpose Charitable: Yes
Religious: Yes
Educational: Yes
Scientific: No
Literary: No
Public Safety: No
Amateur Sports: No
Cruelty Prevention: Yes
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 CAMILLE DYER
Signature Title PRESIDENT
Signature Date 9/26/19

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