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  5. CLAY COUNTY COUNCIL ON AGING, INC.

CLAY COUNTY COUNCIL ON AGING, INC. - Florida Company Profile

Company Details

Entity Name: CLAY COUNTY COUNCIL ON AGING, INC.
Jurisdiction: FLORIDA
Filing Type: Domestic Non-Profit
Status: Inactive

The business entity is inactive. This status may signal operational issues or voluntary closure, raising concerns about the business's ability to repay loans and requiring careful risk assessment by lenders.

Date Filed: 02 May 1974 (51 years ago)
Date of dissolution: 08 Feb 2021 (4 years ago)
Last Event: VOLUNTARY DISS W/ NOTICE
Event Date Filed: 08 Feb 2021 (4 years ago)
Document Number: 729535
FEI/EIN Number 591557913

Federal Employer Identification (FEI) Number assigned by the IRS.
Address: 3530 Enterprise Way, GREEN COVE SPRINGS, FL, 32043, US
Mail Address: P. O. Box 655, GREEN COVE SPRINGS, FL, 32043, US
ZIP code: 32043
County: Clay
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1679730824 2008-05-16 2015-01-26 604 WALNUT STREET, GREEN COVE SPRINGS, FL, 320433322, US 604 WALNUT ST, GREEN COVE SPRINGS, FL, 320433322, US

Contacts
Phone +1 904-284-3134
Fax 9042840296
Phone +1 904-284-5977

Authorized person
Name MR. ANDREW DECANDIS
Role EXECUTIVE DIRECTOR
Phone 9045315020

Taxonomy
Taxonomy Code 302R00000X - Health Maintenance Organization
License Number 5666
State FL
Is Primary No
Taxonomy Code 302R00000X - Health Maintenance Organization
State FL
Is Primary Yes

Other Provider Identifiers
Issuer MEDICAID
Number 070035500
State FL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
CLAY COUNTY 2016 591557913 2017-07-25 CLAY COUNTY COUNCIL ON AGING, INC. 116
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1998-08-01
Business code 813000
Sponsor’s telephone number 9042845977
Plan sponsor’s address 604 WALNUT STREET, GREEN COVE SPRINGS, FL, 32043

Signature of
Role Plan administrator
Date 2017-07-25
Name of individual signing REBECCA KNOWLES
Valid signature Filed with authorized/valid electronic signature
CLAY COUNTY 2015 591557913 2016-05-11 CLAY COUNTY COUNCIL ON AGING, INC. 51
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1998-08-01
Business code 813000
Sponsor’s telephone number 9042845977
Plan sponsor’s address 604 WALNUT STREET, GREEN COVE SPRINGS, FL, 32043

Signature of
Role Plan administrator
Date 2016-05-11
Name of individual signing ANDREW DECANDIS
Valid signature Filed with authorized/valid electronic signature
CLAY COUNTY 2014 591557913 2015-07-21 CLAY COUNTY COUNCIL ON AGING, INC. 108
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1998-08-01
Business code 813000
Sponsor’s telephone number 9042845977
Plan sponsor’s address 604 WALNUT STREET, GREEN COVE SPRINGS, FL, 32043

Signature of
Role Plan administrator
Date 2015-07-21
Name of individual signing REBECCA KNOWLES
Valid signature Filed with authorized/valid electronic signature
CLAY COUNTY 2013 591557913 2014-07-30 CLAY COUNTY COUNCIL ON AGING, INC. 105
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1998-08-01
Business code 813000
Sponsor’s telephone number 9042845977
Plan sponsor’s address 604 WALNUT STREET, GREEN COVE SPRINGS, FL, 32043

Signature of
Role Plan administrator
Date 2014-07-30
Name of individual signing REBECCA KNOWLES
Valid signature Filed with authorized/valid electronic signature
CLAY COUNTY 2012 591557913 2013-08-16 CLAY COUNTY COUNCIL ON AGING, INC. 98
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1998-08-01
Business code 813000
Sponsor’s telephone number 9042845977
Plan sponsor’s address 604 WALNUT STREET, GREEN COVE SPRINGS, FL, 32043

Signature of
Role Plan administrator
Date 2013-08-16
Name of individual signing ALBERT RIZER
Valid signature Filed with authorized/valid electronic signature
CLAY COUNTY 2011 591557913 2012-10-02 CLAY COUNTY COUNCIL ON AGING, INC. 94
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1998-08-01
Business code 813000
Sponsor’s telephone number 9042845977
Plan sponsor’s address 604 WALNUT STREET, GREEN COVE SPRINGS, FL, 32043

Plan administrator’s name and address
Administrator’s EIN 591557913
Plan administrator’s name CLAY COUNTY COUNCIL ON AGING, INC.
Plan administrator’s address 604 WALNUT STREET, GREEN COVE SPRINGS, FL, 32043
Administrator’s telephone number 9042845977

Signature of
Role Plan administrator
Date 2012-10-02
Name of individual signing ALBERT RIZER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2012-10-02
Name of individual signing ALBERT RIZER
Valid signature Filed with authorized/valid electronic signature
CLAY COUNTY COUNCIL ON AGING, INC. 401(K) PLAN 2010 591557913 2011-10-05 CLAY COUNTY COUNCIL ON AGING, INC. 102
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1998-08-01
Business code 813000
Sponsor’s telephone number 9042845977
Plan sponsor’s address 604 WALNUT STREET, GREEN COVE SPRINGS, FL, 32043

Plan administrator’s name and address
Administrator’s EIN 591557913
Plan administrator’s name CLAY COUNTY COUNCIL ON AGING, INC.
Plan administrator’s address 604 WALNUT STREET, GREEN COVE SPRINGS, FL, 32043
Administrator’s telephone number 9042845977

Signature of
Role Plan administrator
Date 2011-10-05
Name of individual signing ALBERT RIZER
Valid signature Filed with authorized/valid electronic signature
CLAY COUNTY COUNCIL ON AGING, INC. 401(K) PLAN 2009 591557913 2010-06-24 CLAY COUNTY COUNCIL ON AGING, INC 109
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1998-08-01
Business code 813000
Sponsor’s telephone number 9042845977
Plan sponsor’s address 604 WALNUT STREET, GREEN COVE SPRINGS, FL, 32043

Plan administrator’s name and address
Administrator’s EIN 591557913
Plan administrator’s name CLAY COUNTY COUNCIL ON AGING, INC.
Plan administrator’s address 604 WALNUT STREET, GREEN COVE, FL, 32043
Administrator’s telephone number 9042845977

Signature of
Role Plan administrator
Date 2010-06-24
Name of individual signing ALBERT RIZER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2010-06-24
Name of individual signing ALBERT RIZER
Valid signature Filed with authorized/valid electronic signature

Key Officers & Management

Name Role Address
Clary Tina President P. O. Box 655, GREEN COVE SPRINGS, FL, 32043
Peeples Eliabeth Vice President 5038 Springbank Road, Green Cove Springs, FL, 32043
Powers John Treasurer P. O. Box 655, GREEN COVE SPRINGS, FL, 32043
Elliott Lynn Secretary P. O. Box 655, GREEN COVE SPRINGS, FL, 32043
Bowles John Past P. O. Box 655, GREEN COVE SPRINGS, FL, 32043
Coleman Ronald Director P. O. Box 655, GREEN COVE SPRINGS, FL, 32043
Bowles John Agent 611 Custer Circle, Orange Park, FL, 32073

Fictitious Names

Registration Number Fictitious Name Status Filed Date Expiration Date Cancellation Date Mailing Address
G16000092363 THE COTTAGE AT RIVER HOUSE EXPIRED 2016-08-25 2021-12-31 - 604 WALNUT ST, GREEN COVE SPRINGS, FL, 32043
G16000019596 JUDY'S PLACE, ADULT DAY PROGRAM EXPIRED 2016-02-23 2021-12-31 - 1701 PARK AVENUE, ORANGE PARK, FL, 32073
G14000060622 CAREGIVER CONNECTION EXPIRED 2014-06-16 2019-12-31 - 604 WALNUT ST., GREEN COVE SPINGS, FL, 32043

Events

Event Type Filed Date Value Description
VOLUNTARY DISS W/ NOTICE 2021-02-08 - -
CHANGE OF PRINCIPAL ADDRESS 2020-06-10 3530 Enterprise Way, 2019, GREEN COVE SPRINGS, FL 32043 -
CHANGE OF MAILING ADDRESS 2019-06-12 3530 Enterprise Way, 2019, GREEN COVE SPRINGS, FL 32043 -
REGISTERED AGENT NAME CHANGED 2018-04-09 Bowles, John -
REGISTERED AGENT ADDRESS CHANGED 2018-04-09 611 Custer Circle, Orange Park, FL 32073 -

Documents

Name Date
CORAPVDWN 2021-02-08
ANNUAL REPORT 2020-06-10
ANNUAL REPORT 2019-06-12
ANNUAL REPORT 2018-04-09
ANNUAL REPORT 2017-04-12
ANNUAL REPORT 2016-04-25
ANNUAL REPORT 2015-03-18
ANNUAL REPORT 2014-04-17
ANNUAL REPORT 2013-04-22
ANNUAL REPORT 2012-04-09

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Companies related by address

No other companies in our directory share the same address as CLAY COUNTY COUNCIL ON AGING, INC.

Date of last update: 02 Apr 2025

Sources: Florida Department of State

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