FORM 1023-EZ for KEY FREE CLINIC

Field Data
EIN 46-2454053
Case Number EO-2016235-000280
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name KEY FREE CLINIC
Organization’s Mailing Address PO BOX 1095
City VAUGHN
State WA
ZIP 98394
Accounting period End 12
Primary contact name PENNY GAZABAT
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

CHUCK WEST
PRESIDENT
PO BOX 856
VAUGHN WA 98394

Officer/Director/Trustee Two

SUSAN BOULERSE
VICE PRESIDENT
136 BRICK KILN RD
FOX ISLAND WA 98333

Officer/Director/Trustee Three

PENNY GAZABAT
TREASURER
16023 59TH ST CT KP N
LAKEBAY WA 98349

Officer/Director/Trustee Four

HEATHER HASSKE
SECRETARY
4615 77TH AVE NW
GIG HARBOR WA 98335

Officer/Director/Trustee Five

JESSICA KENNEDY-SCHLICHER
MEDICAL DIRECTOR
4615 77TH AVE NW
GIG HARBOR WA 98335

Organization’s website KEYFREECLINIC.COM
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 5/6/2013
Organization Incorporation State WA
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E60 - Health Support 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 Yes
One Third Support Gifts No
Benefit of College No
Private Foundation 508(e) No
Seeking Retroactive Reinstatement Yes
Seeking Section 7 Reinstatement No
Correctness Declaration Yes
Signature Name
Signature Title
Signature Date

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