FORM 1023-EZ for ELDERSERVE OF CLAIBORNE COUNTY

Field Data
EIN 81-2025815
Case Number EO-2016092-000366
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name ELDERSERVE OF CLAIBORNE COUNTY
Organization’s Mailing Address PO BOX 326
City TAZEWELL
State TN
ZIP 37879-0326
Accounting period End 12
Primary contact name DENISE WEST
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

JAMES HALL
CHAIRMAN
4244 HWY 33 S
NEW TAZEWELL TN 37825

Officer/Director/Trustee Two

DENISE WEST
VICE-CHAIR
180 JAYCEE LANE
TAZEWELL TN 37879

Officer/Director/Trustee Three

VIRGINIA HALL
SECRETARY
4244 HWY 33 S
NEW TAZEWELL TN 37825

Officer/Director/Trustee Four

TAMARA AUSTIN
TREASURER
592 BARREN CREEK ROAD
NEW TAZEWELL TN 37825

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 3/30/2016
Organization Incorporation State TN
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code W99 - Public, Society Benefit - Multipurpose and Other N.E.C.
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 Yes
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 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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