Fillable Form 1023 Application for Recognition of Exemption 2017

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Form 1023 Application for Recognition of Exemption 2017

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The form you are looking for begins on the next page of this file. Before viewing it,

please see the important update information below.

New Mailing Address

The mailing address for certain forms have change since the forms were last published.

The new mailing address are shown below.

Mailing Address for Forms 1023, 1024, 1024-A, 1028, 5300, 5307, 5310, 5310-A, 5316,

8717, 8718, 8940:

Internal Revenue Service

TE/GE Stop 31A Team 105

P.O. Box 12192

Covington, KY 41012–0192

Deliveries by private delivery service (PDS) should be made to:

Internal Revenue Service

7940 Kentucky Drive

TE/GE Stop 31A Team 105

Florence, KY 41042

This update supplements these forms’ instructions. Filers should rely on this update for

the change described, which will be incorporated into the next revision of the form’s

instructions.

This page intentionally left blank.

Form 1023

(Rev. December 2017)

Department of the Treasury

Internal Revenue Service

Application for Recognition of Exemption

Under Section 501(c)(3) of the Internal Revenue Code

▶

Do not enter social security numbers on this form as it may be made public.

▶

Go to www.irs.gov/Form1023 for instructions and the latest information.

OMB No. 1545-0056

Note: If exempt status is

approved, this

application will be open

for public inspection.

Use the instructions to complete this application and for a definition of all bold items. For additional help, call IRS Exempt

Organizations Customer Account Services toll-free at 1-877-829-5500. Visit our website at www.irs.gov for forms and publications. If

the required information and documents are not submitted with payment of the appropriate user fee, the application may be returned

to you.

Attach additional sheets to this application if you need more space to answer fully. Put your name and EIN on each sheet and

identify each answer by Part and line number. Complete Parts I – XI of Form 1023 and submit only those Schedules (A through H) that

apply to you.

Part I

Identification of Applicant

Full name of organization (exactly as it appears in your organizing document)

c/o Name (if applicable)

Mailing address (Number and street) (see instructions)

Room/Suite

4 Employer Identification Number (EIN)

City or town, state or country, and ZIP + 4

Month the annual accounting period ends (01 – 12)

6 Primary contact (officer, director, trustee, or authorized representative)

a Name:

b Phone:

Fax: (optional)

Are you represented by an authorized representative, such as an attorney or accountant? If “Yes,”

provide the authorized representative’s name, and the name and address of the authorized

representative’s firm. Include a completed Form 2848, Power of Attorney and Declaration of

Representative, with your application if you would like us to communicate with your representative.

Yes No

Was a person who is not one of your officers, directors, trustees, employees, or an authorized

representative listed in line 7, paid, or promised payment, to help plan, manage, or advise you about

the structure or activities of your organization, or about your financial or tax matters? If “Yes,” provide

the person’s name, the name and address of the person’s firm, the amounts paid or promised to be

paid, and describe that person’s role.

Yes No

9a Organization’s website:

Organization’s email: (optional)

10 Certain organizations are not required to file an information return (Form 990 or Form 990-EZ). If you

are granted tax-exemption, are you claiming to be excused from filing Form 990 or Form 990-EZ? If

“Yes,” explain. See the instructions for a description of organizations not required to file Form 990 or

Form 990-EZ.

Yes No

Date incorporated if a corporation, or formed, if other than a corporation.

(MM/DD/YYYY) / /

12 Were you formed under the laws of a foreign country? Yes No

If “Yes,” state the country.

For Paperwork Reduction Act Notice, see instructions.

Cat. No. 17133K

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 2

Part II Organizational Structure

You must be a corporation (including a limited liability company), an unincorporated association, or a trust to be tax exempt.

See instructions. DO NOT file this form unless you can check “Yes” on lines 1, 2, 3, or 4.

Are you a corporation? If “Yes,” attach a copy of your articles of incorporation showing certification of

filing with the appropriate state agency. Include copies of any amendments to your articles and be sure

they also show state filing certification.

Yes No

Are you a limited liability company (LLC)? If “Yes,” attach a copy of your articles of organization showing

certification of filing with the appropriate state agency. Also, if you adopted an operating agreement, attach

a copy. Include copies of any amendments to your articles and be sure they show state filing certification.

Refer to the instructions for circumstances when an LLC should not file its own exemption application.

Yes No

Are you an unincorporated association? If “Yes,” attach a copy of your articles of association,

constitution, or other similar organizing document that is dated and includes at least two signatures.

Include signed and dated copies of any amendments.

Yes No

Are you a trust? If “Yes,” attach a signed and dated copy of your trust agreement. Include signed and

dated copies of any amendments.

Yes No

Have you been funded? If “No,” explain how you are formed without anything of value placed in trust.

Yes No

Have you adopted bylaws? If “Yes,” attach a current copy showing date of adoption. If “No,” explain

how your officers, directors, or trustees are selected.

Yes No

Part III

Required Provisions in Your Organizing Document

The following questions are designed to ensure that when you file this application, your organizing document contains the required provisions

to meet the organizational test under section 501(c)(3). Unless you can check the boxes in both lines 1 and 2, your organizing document

does not meet the organizational test. DO NOT file this application until you have amended your organizing document. Submit your

original and amended organizing documents (showing state filing certification if you are a corporation or an LLC) with your application.

Section 501(c)(3) requires that your organizing document state your exempt purpose(s), such as charitable,

religious, educational, and/or scientific purposes. Check the box to confirm that your organizing document meets

this requirement. Describe specifically where your organizing document meets this requirement, such as a reference

to a particular article or section in your organizing document. Refer to the instructions for exempt purpose language.

Location of Purpose Clause (Page, Article, and Paragraph):

2 a

Section 501(c)(3) requires that upon dissolution of your organization, your remaining assets must be used exclusively

for exempt purposes, such as charitable, religious, educational, and/or scientific purposes. Check the box on line 2a to

confirm that your organizing document meets this requirement by express provision for the distribution of assets upon

dissolution. If you rely on state law for your dissolution provision, do not check the box on line 2a and go to line 2c.

b If you checked the box on line 2a, specify the location of your dissolution clause (Page, Article, and Paragraph).

Do not complete line 2c if you checked box 2a.

See the instructions for information about the operation of state law in your particular state. Check this box if you

rely on operation of state law for your dissolution provision and indicate the state:

Part IV Narrative Description of Your Activities

Using an attachment, describe your past, present, and planned activities in a narrative. If you believe that you have already provided some of

this information in response to other parts of this application, you may summarize that information here and refer to the specific parts of the

application for supporting details. You may also attach representative copies of newsletters, brochures, or similar documents for supporting

details to this narrative. Remember that if this application is approved, it will be open for public inspection. Therefore, your narrative

description of activities should be thorough and accurate. Refer to the instructions for information that must be included in your description.

Part V

Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees,

Employees, and Independent Contractors

List the names, titles, and mailing addresses of all of your officers, directors, and trustees. For each person listed, state their

total annual compensation, or proposed compensation, for all services to the organization, whether as an officer, employee, or

other position. Use actual figures, if available. Enter “none” if no compensation is or will be paid. If additional space is needed,

attach a separate sheet. Refer to the instructions for information on what to include as compensation.

Name Title Mailing address

Compensation amount

(annual actual or estimated)

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 3

Part V

Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees, Employees,

and Independent Contractors (Continued)

List the names, titles, and mailing addresses of each of your five highest compensated employees who receive or will receive

compensation of more than $50,000 per year. Use the actual figure, if available. Refer to the instructions for information on

what to include as compensation. Do not include officers, directors, or trustees listed in line 1a.

Name Title Mailing address

Compensation amount

(annual actual or estimated)

List the names, names of businesses, and mailing addresses of your five highest compensated independent contractors that

receive or will receive compensation of more than $50,000 per year. Use the actual figure, if available. Refer to the instructions

for information on what to include as compensation.

Name Title Mailing address

Compensation amount

(annual actual or estimated)

The following “Yes” or “No” questions relate to past, present, or planned relationships, transactions, or agreements with your officers,

directors, trustees, highest compensated employees, and highest compensated independent contractors listed in lines 1a, 1b, and 1c.

Are any of your officers, directors, or trustees related to each other through family or business

relationships? If “Yes,” identify the individuals and explain the relationship.

Yes No

Do you have a business relationship with any of your officers, directors, or trustees other than through

their position as an officer, director, or trustee? If “Yes,” identify the individuals and describe the business

relationship with each of your officers, directors, or trustees.

Yes No

Are any of your officers, directors, or trustees related to your highest compensated employees or highest

compensated independent contractors listed on lines 1b or 1c through family or business relationships? If

“Yes,” identify the individuals and explain the relationship.

Yes No

3 a

For each of your officers, directors, trustees, highest compensated employees, and highest

compensated independent contractors listed on lines 1a, 1b, or 1c, attach a list showing their name,

qualifications, average hours worked, and duties.

Do any of your officers, directors, trustees, highest compensated employees, and highest compensated

independent contractors listed on lines 1a, 1b, or 1c receive compensation from any other organizations,

whether tax exempt or taxable, that are related to you through common control? If “Yes,” identify the

individuals, explain the relationship between you and the other organization, and describe the

compensation arrangement.

Yes No

In establishing the compensation for your officers, directors, trustees, highest compensated employees,

and highest compensated independent contractors listed on lines 1a, 1b, and 1c, the following practices

are recommended, although they are not required to obtain exemption. Answer “Yes” to all the practices

you use.

Do you or will the individuals that approve compensation arrangements follow a conflict of interest policy?

Yes No

b Do you or will you approve compensation arrangements in advance of paying compensation?

Yes No

c Do you or will you document in writing the date and terms of approved compensation arrangements?

Yes No

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 4

Part V

Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees, Employees,

and Independent Contractors (Continued)

Do you or will you record in writing the decision made by each individual who decided or voted on

compensation arrangements?

Yes No

Do you or will you approve compensation arrangements based on information about compensation paid by

similarly situated taxable or tax-exempt organizations for similar services, current compensation surveys

compiled by independent firms, or actual written offers from similarly situated organizations? Refer to the

instructions for Part V, lines 1a, 1b, and 1c, for information on what to include as compensation.

Yes No

Do you or will you record in writing both the information on which you relied to base your decision and its

source?

Yes No

If you answered “No” to any item on lines 4a through 4f, describe how you set compensation that is

reasonable for your officers, directors, trustees, highest compensated employees, and highest

compensated independent contractors listed in Part V, lines 1a, 1b, and 1c.

Have you adopted a conflict of interest policy consistent with the sample conflict of interest policy in

Appendix A to the instructions? If “Yes,” provide a copy of the policy and explain how the policy has

been adopted, such as by resolution of your governing board. If “No,” answer lines 5b and 5c.

Yes No

What procedures will you follow to assure that persons who have a conflict of interest will not have

influence over you for setting their own compensation?

What procedures will you follow to assure that persons who have a conflict of interest will not have

influence over you regarding business deals with themselves?

Note: A conflict of interest policy is recommended though it is not required to obtain exemption.

Hospitals, see Schedule C, Section I, line 14.

Do you or will you compensate any of your officers, directors, trustees, highest compensated employees, and highest

compensated independent contractors listed in lines 1a, 1b, or 1c through non-fixed payments, such as discretionary

bonuses or revenue-based payments? If “Yes,” describe all non-fixed compensation arrangements, including how the

amounts are determined, who is eligible for such arrangements, whether you place a limitation on total compensation,

and how you determine or will determine that you pay no more than reasonable compensation for services. Refer to

the instructions for Part V, lines 1a, 1b, and 1c, for information on what to include as compensation.

Yes No

Do you or will you compensate any of your employees, other than your officers, directors, trustees, or your

five highest compensated employees who receive or will receive compensation of more than $50,000 per

year, through non-fixed payments, such as discretionary bonuses or revenue-based payments? If “Yes,”

describe all non-fixed compensation arrangements, including how the amounts are or will be determined, who

is or will be eligible for such arrangements, whether you place or will place a limitation on total compensation,

and how you determine or will determine that you pay no more than reasonable compensation for services.

Refer to the instructions for Part V, lines 1a, 1b, and 1c, for information on what to include as compensation.

Yes No

Do you or will you purchase any goods, services, or assets from any of your officers, directors, trustees, highest

compensated employees, or highest compensated independent contractors listed in lines 1a, 1b, or 1c? If “Yes,”

describe any such purchase that you made or intend to make, from whom you make or will make such purchases, how

the terms are or will be negotiated at arm’s length, and explain how you determine or will determine that you pay no

more than fair market value. Attach copies of any written contracts or other agreements relating to such purchases.

Yes No

Do you or will you sell any goods, services, or assets to any of your officers, directors, trustees, highest

compensated employees, or highest compensated independent contractors listed in lines 1a, 1b, or 1c? If “Yes,”

describe any such sales that you made or intend to make, to whom you make or will make such sales, how the

terms are or will be negotiated at arm’s length, and explain how you determine or will determine you are or will be

paid at least fair market value. Attach copies of any written contracts or other agreements relating to such sales.

Yes No

Do you or will you have any leases, contracts, loans, or other agreements with your officers, directors,

trustees, highest compensated employees, or highest compensated independent contractors listed in

lines 1a, 1b, or 1c? If “Yes,” provide the information requested in lines 8b through 8f.

Yes No

b Describe any written or oral arrangements that you made or intend to make.

c Identify with whom you have or will have such arrangements.

d Explain how the terms are or will be negotiated at arm’s length.

Explain how you determine you pay no more than fair market value or you are paid at least fair market value.

f Attach copies of any signed leases, contracts, loans, or other agreements relating to such arrangements.

9a Do you or will you have any leases, contracts, loans, or other agreements with any organization in which

any of your officers, directors, or trustees are also officers, directors, or trustees, or in which any

individual officer, director, or trustee owns more than a 35% interest? If “Yes,” provide the information

requested in lines 9b through 9f.

Yes No

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 5

Part V

Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees,

Employees, and Independent Contractors (Continued)

b Describe any written or oral arrangements you made or intend to make.

c Identify with whom you have or will have such arrangements.

d Explain how the terms are or will be negotiated at arm’s length.

Explain how you determine or will determine you pay no more than fair market value or that you are paid

at least fair market value.

f Attach a copy of any signed leases, contracts, loans, or other agreements relating to such arrangements.

Part VI Your Members and Other Individuals and Organizations That Receive Benefits From You

The following “Yes” or “No” questions relate to goods, services, and funds you provide to individuals and organizations as part of your

activities. Your answers should pertain to past, present, and planned activities. See instructions.

1 a

In carrying out your exempt purposes, do you provide goods, services, or funds to individuals? If “Yes,”

describe each program that provides goods, services, or funds to individuals.

Yes No

In carrying out your exempt purposes, do you provide goods, services, or funds to organizations? If

“Yes,” describe each program that provides goods, services, or funds to organizations.

Yes No

2 Do any of your programs limit the provision of goods, services, or funds to a specific individual or group

of specific individuals? For example, answer “Yes,” if goods, services, or funds are provided only for a

particular individual, your members, individuals who work for a particular employer, or graduates of a

particular school. If “Yes,” explain the limitation and how recipients are selected for each program.

Yes No

3 Do any individuals who receive goods, services, or funds through your programs have a family or

business relationship with any officer, director, trustee, or with any of your highest compensated

employees or highest compensated independent contractors listed in Part V, lines 1a, 1b, and 1c? If

“Yes,” explain how these related individuals are eligible for goods, services, or funds.

Yes No

Part VII Your History

The following “Yes” or “No” questions relate to your history. See instructions.

1 Are you a successor to another organization? Answer “Yes,” if you have taken or will take over the

activities of another organization; you took over 25% or more of the fair market value of the net assets of

another organization; or you were established upon the conversion of an organization from for-profit to

nonprofit status. If “Yes,” complete Schedule G.

Yes No

Are you submitting this application more than 27 months after the end of the month in which you were

legally formed? If “Yes,” complete Schedule E.

Yes No

Part VIII Your Specific Activities

The following “Yes” or “No” questions relate to specific activities that you may conduct. Check the appropriate box. Your answers

should pertain to past, present, and planned activities. See instructions.

Do you support or oppose candidates in political campaigns in any way? If “Yes,” explain.

Yes No

2 a

Do you attempt to influence legislation? If “Yes,” explain how you attempt to influence legislation and

complete line 2b. If “No,” go to line 3a.

Yes No

Have you made or are you making an election to have your legislative activities measured by

expenditures by filing Form 5768? If “Yes,” attach a copy of the Form 5768 that was already filed or

attach a completed Form 5768 that you are filing with this application. If “No,” describe whether your

attempts to influence legislation are a substantial part of your activities. Include the time and money

spent on your attempts to influence legislation as compared to your total activities.

Yes No

Do you or will you operate bingo or gaming activities? If “Yes,” describe who conducts them, and list all

revenue received or expected to be received and expenses paid or expected to be paid in operating

these activities. Revenue and expenses should be provided for the time periods specified in Part IX,

Financial Data.

Yes No

Do you or will you enter into contracts or other agreements with individuals or organizations to conduct

bingo or gaming for you? If “Yes,” describe any written or oral arrangements that you made or intend to

make, identify with whom you have or will have such arrangements, explain how the terms are or will be

negotiated at arm’s length, and explain how you determine or will determine you pay no more than fair

market value or you will be paid at least fair market value. Attach copies or any written contracts or other

agreements relating to such arrangements.

Yes No

List the states and local jurisdictions, including Indian Reservations, in which you conduct or will conduct

gaming or bingo.

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 6

Part VIII Your Specific Activities (Continued)

4 a

Do you or will you undertake fundraising? If “Yes,” check all the fundraising programs you do or will

conduct. See instructions.

Yes No

mail solicitations phone solicitations

email solicitations accept donations on your website

personal solicitations receive donations from another organization’s website

vehicle, boat, plane, or similar donations government grant solicitations

foundation grant solicitations Other

Attach a description of each fundraising program.

Do you or will you have written or oral contracts with any individuals or organizations to raise funds for

you? If “Yes,” describe these activities. Include all revenue and expenses from these activities and state

who conducts them. Revenue and expenses should be provided for the time periods specified in Part IX,

Financial Data. Also, attach a copy of any contracts or agreements.

Yes No

Do you or will you engage in fundraising activities for other organizations? If “Yes,” describe these

arrangements. Include a description of the organizations for which you raise funds and attach copies of

all contracts or agreements.

Yes No

List all states and local jurisdictions in which you conduct fundraising. For each state or local jurisdiction

listed, specify whether you fundraise for your own organization, you fundraise for another organization, or

another organization fundraises for you.

Do you or will you maintain separate accounts for any contributor under which the contributor has the

right to advise on the use or distribution of funds? Answer “Yes” if the donor may provide advice on the

types of investments, distributions from the types of investments, or the distribution from the donor’s

contribution account. If “Yes,” describe this program, including the type of advice that may be provided

and submit copies of any written materials provided to donors.

Yes No

Are you affiliated with a governmental unit? If “Yes,” explain.

Yes No

6a Do you or will you engage in economic development? If “Yes,” describe your program. Yes No

Describe in full who benefits from your economic development activities and how the activities promote

exempt purposes.

Do or will persons other than your employees or volunteers develop your facilities? If “Yes,” describe

each facility, the role of the developer, and any business or family relationship(s) between the developer

and your officers, directors, or trustees.

Yes No

Do or will persons other than your employees or volunteers manage your activities or facilities? If “Yes,”

describe each activity and facility, the role of the manager, and any business or family relationship(s)

between the manager and your officers, directors, or trustees.

Yes No

If there is a business or family relationship between any manager or developer and your officers,

directors, or trustees, identify the individuals, explain the relationship, describe how contracts are

negotiated at arm’s length so that you pay no more than fair market value, and submit a copy of any

contracts or other agreements.

Do you or will you enter into joint ventures, including partnerships or limited liability companies

treated as partnerships, in which you share profits and losses with partners other than section 501(c)(3)

organizations? If “Yes,” describe the activities of these joint ventures in which you participate.

Yes No

Are you applying for exemption as a childcare organization under section 501(k)? If “Yes,” answer lines

9b through 9d. If “No,” go to line 10.

Yes No

Do you provide childcare so that parents or caretakers of children you care for can be gainfully

employed (see instructions)? If “No,” explain how you qualify as a childcare organization described in

section 501(k).

Yes No

Of the children for whom you provide childcare, are 85% or more of them cared for by you to enable their

parents or caretakers to be gainfully employed (see instructions)? If “No,” explain how you qualify as a

childcare organization described in section 501(k).

Yes No

Are your services available to the general public? If “No,” describe the specific group of people for whom

your activities are available. Also, see the instructions and explain how you qualify as a childcare

organization described in section 501(k).

Yes No

Do you or will you publish, own, or have rights in music, literature, tapes, artworks, choreography,

scientific discoveries, or other intellectual property? If “Yes,” explain. Describe who owns or will own

any copyrights, patents, or trademarks, whether fees are or will be charged, how the fees are

determined, and how any items are or will be produced, distributed, and marketed.

Yes No

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 7

Part VIII Your Specific Activities (Continued)

Do you or will you accept contributions of: real property; conservation easements; closely held

securities; intellectual property such as patents, trademarks, and copyrights; works of music or art;

licenses; royalties; automobiles, boats, planes, or other vehicles; or collectibles of any type? If “Yes,”

describe each type of contribution, any conditions imposed by the donor on the contribution, and any

agreements with the donor regarding the contribution.

Yes No

12 a

Do you or will you operate in a foreign country or countries? If “Yes,” answer lines 12b through 12d. If

“No,” go to line 13a.

Yes No

Name the foreign countries and regions within the countries in which you operate.

c Describe your operations in each country and region in which you operate.

Describe how your operations in each country and region further your exempt purposes.

13a

Do you or will you make grants, loans, or other distributions to organization(s)? If “Yes,” answer lines 13b

through 13g. If “No,” go to line 14a.

Yes No

b Describe how your grants, loans, or other distributions to organizations further your exempt purposes.

c Do you have written contracts with each of these organizations? If “Yes,” attach a copy of each contract. Yes No

d Identify each recipient organization and any relationship between you and the recipient organization.

e Describe the records you keep with respect to the grants, loans, or other distributions you make.

f Describe your selection process, including whether you do any of the following.

(i) Do you require an application form? If “Yes,” attach a copy of the form.

Yes No

(ii) Do you require a grant proposal? If “Yes,” describe whether the grant proposal specifies your

responsibilities and those of the grantee, obligates the grantee to use the grant funds only for the

purposes for which the grant was made, provides for periodic written reports concerning the use of

grant funds, requires a final written report and an accounting of how grant funds were used, and

acknowledges your authority to withhold and/or recover grant funds in case such funds are, or appear

to be, misused.

Yes No

Describe your procedures for oversight of distributions that assure you the resources are used to further

your exempt purposes, including whether you require periodic and final reports on the use of resources.

14 a

Do you or will you make grants, loans, or other distributions to foreign organizations? If “Yes,” answer

lines 14b through 14f. If “No,” go to line 15.

Yes No

Provide the name of each foreign organization, the country and regions within a country in which each

foreign organization operates, and describe any relationship you have with each foreign organization.

Does any foreign organization listed in line 14b accept contributions earmarked for a specific country or

specific organization? If “Yes,” list all earmarked organizations or countries.

Yes No

Do your contributors know that you have ultimate authority to use contributions made to you at your

discretion for purposes consistent with your exempt purposes? If “Yes,” describe how you relay this

information to contributors.

Yes No

e Do you or will you make pre-grant inquiries about the recipient organization? If “Yes,” describe these

inquiries, including whether you inquire about the recipient’s financial status, its tax-exempt status under

the Internal Revenue Code, its ability to accomplish the purpose for which the resources are provided,

and other relevant information.

Yes No

Do you or will you use any additional procedures to ensure that your distributions to foreign

organizations are used in furtherance of your exempt purposes? If “Yes,” describe these procedures,

including site visits by your employees or compliance checks by impartial experts, to verify that grant

funds are being used appropriately.

Yes No

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 8

Part VIII Your Specific Activities (Continued)

15 Do you have a close connection with any organizations? If “Yes,” explain.

Yes No

Are you applying for exemption as a cooperative hospital service organization under section 501(e)? If

“Yes,” explain.

Yes No

Are you applying for exemption as a cooperative service organization of operating educational

organizations under section 501(f)? If “Yes,” explain.

Yes No

18 Are you applying for exemption as a charitable risk pool under section 501(n)? If “Yes,” explain.

Yes No

Do you or will you operate a school? If “Yes,” complete Schedule B. Answer “Yes,” whether you operate

a school as your main function or as a secondary activity.

Yes No

20 Is your main function to provide hospital or medical care? If “Yes,” complete Schedule C.

Yes No

Do you or will you provide low-income housing or housing for the elderly or handicapped? If “Yes,”

complete Schedule F.

Yes No

Do you or will you provide scholarships, fellowships, educational loans, or other educational grants to

individuals, including grants for travel, study, or other similar purposes? If “Yes,” complete Schedule H.

Yes No

Note: Private foundations may use Schedule H to request advance approval of individual grant

procedures.

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 9

Part IX Financial Data

For purposes of this schedule, years in existence refer to completed tax years.

1. If in existence less than 5 years, complete the statement for each year in existence and provide projections of your likely

revenues and expenses based on a reasonable and good faith estimate of your future finances for a total of:

a. Three years of financial information if you have not completed one tax year, or

b. Four years of financial information if you have completed one tax year. See instructions.

2. If in existence 5 or more years, complete the schedule for the most recent 5 tax years. You will need to provide a separate

statement that includes information about the most recent 5 tax years because the data table in Part IX has not been

updated to provide for a 5th year. See instructions.

A. Statement of Revenues and Expenses

Type of revenue or expense

Current tax year

(a) From

3 prior tax years or 2 succeeding tax years

(b) From

(d) From

(e) Provide Total for

(a) through (d)

Revenues

1 Gifts, grants, and

contributions received (do not

include unusual grants)

2 Membership fees received

3 Gross investment income

Net unrelated business

income

5 Taxes levied for your benefit

Value of services or facilities

furnished by a governmental unit

without charge (not including the

value of services generally furnished

to the public without charge)

7 Any revenue not otherwise listed

above or in lines 9–12 below

(attach an itemized list)

8 Total of lines 1 through 7

Gross receipts from admissions,

merchandise sold or services

performed, or furnishing of facilities in

any activity that is related to your

exempt purposes (attach itemized list)

10 Total of lines 8 and 9

11 Net gain or loss on sale of

capital assets (attach

schedule and see instructions)

12 Unusual grants

Total Revenue

Add lines 10 through 12

Expenses

14 Fundraising expenses

15 Contributions, gifts, grants,

and similar amounts paid out

(attach an itemized list)

16 Disbursements to or for the

benefit of members (attach an

itemized list)

Compensation of officers,

directors, and trustees

18 Other salaries and wages

19 Interest expense

20 Occupancy (rent, utilities, etc.)

21 Depreciation and depletion

22 Professional fees

Any expense not otherwise

classified, such as program

services (attach itemized list)

Total Expenses

Add lines 14 through 23

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 10

Part IX Financial Data (Continued)

B. Balance Sheet (for your most recently completed tax year)

Year End:

Assets

1 Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(Whole dollars)

2 Accounts receivable, net . . . . . . . . . . . . . . . . . . . . . . . . . .

3 Inventories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

4 Bonds and notes receivable (attach an itemized list) . . . . . . . . . . . . . . . . . 4

5 Corporate stocks (attach an itemized list) . . . . . . . . . . . . . . . . . . . . 5

6 Loans receivable (attach an itemized list) . . . . . . . . . . . . . . . . . . . . 6

7 Other investments (attach an itemized list) . . . . . . . . . . . . . . . . . . . . 7

8 Depreciable and depletable assets (attach an itemized list) . . . . . . . . . . . . . . 8

9 Land . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

10 Other assets (attach an itemized list) . . . . . . . . . . . . . . . . . . . . . . 10

11 Total Assets (add lines 1 through 10) . . . . . . . . . . . . . . . . . . . . . . 11

Liabilities

12 Accounts payable . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13 Contributions, gifts, grants, etc. payable . . . . . . . . . . . . . . . . . . . . 13

14 Mortgages and notes payable (attach an itemized list) . . . . . . . . . . . . . . . . 14

15 Other liabilities (attach an itemized list) . . . . . . . . . . . . . . . . . . . . . 15

16 Total Liabilities (add lines 12 through 15) . . . . . . . . . . . . . . . . . . . . 16

Fund Balances or Net Assets

17 Total fund balances or net assets . . . . . . . . . . . . . . . . . . . . . . .

18 Total Liabilities and Fund Balances or Net Assets (add lines 16 and 17) . . . . . . . . . . 18

Have there been any substantial changes in your assets or liabilities since the end of the period

shown above? If “Yes,” explain.

Yes No

Part X Public Charity Status

Part X is designed to classify you as an organization that is either a private foundation or a public charity. Public charity status is a

more favorable tax status than private foundation status. If you are a private foundation, Part X is designed to further determine

whether you are a private operating foundation. See instructions.

1 a

Are you a private foundation? If “Yes,” go to line 1b. If “No,” go to line 5 and proceed as instructed. If you

are unsure, see the instructions.

Yes No

As a private foundation, section 508(e) requires special provisions in your organizing document in

addition to those that apply to all organizations described in section 501(c)(3). Check the box to confirm

that your organizing document meets this requirement, whether by express provision or by reliance on

operation of state law. Attach a statement that describes specifically where your organizing document

meets this requirement, such as a reference to a particular article or section in your organizing document

or by operation of state law. See the instructions, including Appendix B, for information about the special

provisions that need to be contained in your organizing document. Go to line 2.

Are you a private operating foundation? To be a private operating foundation you must engage directly in

the active conduct of charitable, religious, educational, and similar activities, as opposed to indirectly

carrying out these activities by providing grants to individuals or other organizations. If “Yes,” go to line 3.

If “No,” go to the signature section of Part XI.

Yes No

Have you existed for one or more years? If “Yes,” attach financial information showing that you are a

private operating foundation; go to the signature section of Part XI. If “No,” continue to line 4.

Yes No

Have you attached either (1) an affidavit or opinion of counsel, (including a written affidavit or opinion

from a certified public accountant or accounting firm with expertise regarding this tax law matter), that

sets forth facts concerning your operations and support to demonstrate that you are likely to satisfy the

requirements to be classified as a private operating foundation; or (2) a statement describing your

proposed operations as a private operating foundation?

Yes No

If you answered “No” to line 1a, indicate the type of public charity status you are requesting by checking one of the choices

below. You may check only one box.

The organization is not a private foundation because it is:

a 509(a)(1) and 170(b)(1)(A)(i)—a church or a convention or association of churches. Complete and attach Schedule A.

b 509(a)(1) and 170(b)(1)(A)(ii)—a school. Complete and attach Schedule B.

509(a)(1) and 170(b)(1)(A)(iii)—a hospital, a cooperative hospital service organization, or a medical research

organization operated in conjunction with a hospital. Complete and attach Schedule C.

509(a)(3)—an organization supporting either one or more organizations described in line 5a through c, f, h, or i or a

publicly supported section 501(c)(4), (5), or (6) organization. Complete and attach Schedule D.

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 11

Part X Public Charity Status (Continued)

e 509(a)(4) – an organization organized and operated exclusively for testing for public safety.

509(a)(1) and 170(b)(1)(A)(iv) – an organization operated for the benefit of a college or university that is owned or

operated by a governmental unit.

509(a)(1) and 170(b)(1)(A)(ix) – an agricultural research organization directly engaged in the continuous active

conduct of agricultural research in conjunction with a college or university.

509(a)(1) and 170(b)(1)(A)(vi) – an organization that receives a substantial part of its financial support in the form

of contributions from publicly supported organizations, from a governmental unit, or from the general public.

509(a)(2) – an organization that normally receives not more than one-third of its financial support from gross

investment income and receives more than one-third of its financial support from contributions, membership

fees, and gross receipts from activities related to its exempt functions (subject to certain exceptions).

A publicly supported organization, but unsure if it is described in 5h or 5i. You would like the IRS to decide the

correct status.

If you checked box h, i, or j in question 5 above, and you have been in existence more than 5 years, you must confirm

your public support status. Answer line 6a if you checked box h in line 5 above. Answer line 6b if you checked box i in

line 5 above. If you checked box j in line 5 above, answer both lines 6a and 6b.

a (i)

Enter 2% of line 8, column (e) on Part IX-A Statement of Revenues and Expenses

(ii)

Attach a list showing the name and amount contributed by each person, company, or organization whose gifts

totaled more than the 2% amount. If the answer is “None,” state this.

(i)

For each year amounts are included on lines 1, 2, and 9 of Part IX-A Statement of Revenues and Expenses, attach

a list showing the name and amount received from each disqualified person.

If the answer is “None,” state this.

(ii)

For each year amounts were included on line 9 of Part IX-A Statement of Revenues and Expenses, attach a list

showing the name of and amount received from each payer, other than a disqualified person, whose payments

were more than the larger of (1) 1% of Line 10, Part IX-A Statement of Revenues and Expenses, or (2) $5,000.

the answer is “None,” state this.

Did you receive any unusual grants during any of the years shown on Part IX-A Statement of

Revenues and Expenses? If “Yes,” attach a list including the name of the contributor, the date and

amount of the grant, a brief description of the grant, and explain why it is unusual.

Yes No

Part XI User Fee Information and Signature

You must include the correct user fee payment with this application. If you do not submit the correct user fee, we will not

process the application and we will return it to you. Your check or money order must be made payable to the United States

Treasury. User fees are subject to change. Check our website at www.irs.gov and type “Exempt Organizations User Fee” in

the search box, or call Customer Account Services at 1-877-829-5500 for current information.

Enter the amount of the user fee paid:

I declare under the penalties of perjury that I am authorized to sign this application on behalf of the above organization and that I have examined this

application, including the accompanying schedules and attachments, and to the best of my knowledge it is true, correct, and complete.

Please

Sign

Here

▲

(Signature of Officer, Director, Trustee, or other

authorized official)

(Type or print name of signer)

(Date)

(Type or print title or authority of signer)

Form 1023 (Rev. 12-2017)

[This page left blank intentionally]

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 13

Schedule A. Churches

1 a

Do you have a written creed, statement of faith, or summary of beliefs? If “Yes,” attach copies of

relevant documents.

Yes No

Do you have a form of worship? If “Yes,” describe your form of worship.

Yes No

2 a

Do you have a formal code of doctrine and discipline? If “Yes,” describe your code of doctrine and

discipline.

Yes No

b Do you have a distinct religious history? If “Yes,” describe your religious history. Yes No

Do you have a literature of your own? If “Yes,” describe your literature.

Yes No

3 Describe the organization’s religious hierarchy or ecclesiastical government.

Do you have regularly scheduled religious services? If “Yes,” describe the nature of the services and

provide representative copies of relevant literature such as church bulletins.

Yes No

What is the average attendance at your regularly scheduled religious services?

Do you have an established place of worship? If “Yes,” refer to the instructions for the information

required.

Yes No

Do you own the property where you have an established place of worship?

Yes No

Do you have an established congregation or other regular membership group? If “No,” refer to the

instructions.

Yes No

How many members do you have?

8 a

Do you have a process by which an individual becomes a member? If “Yes,” describe the process and

complete lines 8b–8d, below.

Yes No

If you have members, do your members have voting rights, rights to participate in religious functions, or

other rights? If “Yes,” describe the rights your members have.

Yes No

c May your members be associated with another denomination or church? Yes No

Are all of your members part of the same family?

Yes No

Do you conduct baptisms, weddings, funerals, etc.?

Yes No

Do you have a school for the religious instruction of the young?

Yes No

11a

Do you have a minister or religious leader? If “Yes,” describe this person’s role and explain whether the

minister or religious leader was ordained, commissioned, or licensed after a prescribed course of study.

Yes No

Do you have schools for the preparation of your ordained ministers or religious leaders?

Yes No

Is your minister or religious leader also one of your officers, directors, or trustees?

Yes No

Do you ordain, commission, or license ministers or religious leaders? If “Yes,” describe the requirements

for ordination, commission, or licensure.

Yes No

Are you part of a group of churches with similar beliefs and structures? If “Yes,” explain. Include the

name of the group of churches.

Yes No

Do you issue church charters? If “Yes,” describe the requirements for issuing a charter.

Yes No

Did you pay a fee for a church charter? If “Yes,” attach a copy of the charter.

Yes No

Do you have other information you believe should be considered regarding your status as a church?

If “Yes,” explain.

Yes No

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 14

Schedule B. Schools, Colleges, and Universities

If you operate a school as an activity, complete Schedule B

Section I Operational Information

Do you normally have a regularly scheduled curriculum, a regular faculty of qualified teachers, a regularly

enrolled student body, and facilities where your educational activities are regularly carried on? If “No,” do

not complete the remainder of Schedule B.

Yes No

Is the primary function of your school the presentation of formal instruction? If “Yes,” describe your

school in terms of whether it is an elementary, secondary, college, technical, or other type of school. If

“No,” do not complete the remainder of Schedule B.

Yes No

2 a

Are you a public school because you are operated by a state or subdivision of a state? If “Yes,” explain

how you are operated by a state or subdivision of a state. Do not complete the remainder of Schedule B.

Yes No

Are you a public school because you are operated wholly or predominantly from government funds or

property? If “Yes,” explain how you are operated wholly or predominantly from government funds or

property. Submit a copy of your funding agreement regarding government funding. Do not complete the

remainder of Schedule B.

Yes No

3 In what public school district, county, and state are you located?

Were you formed or substantially expanded at the time of public school desegregation in the above

school district or county?

Yes No

Has a state or federal administrative agency or judicial body ever determined that you are racially

discriminatory? If “Yes,” explain.

Yes No

Has your right to receive financial aid or assistance from a governmental agency ever been revoked or

suspended? If “Yes,” explain.

Yes No

Do you or will you contract with another organization to develop, build, market, or finance your facilities?

If “Yes,” explain how that entity is selected, explain how the terms of any contracts or other agreements

are negotiated at arm’s length, and explain how you determine that you will pay no more than fair market

value for services.

Yes No

Note: Make sure your answer is consistent with the information provided in Part VIII, line 7a.

8 Do you or will you manage your activities or facilities through your own employees or volunteers? If “No,”

attach a statement describing the activities that will be managed by others, the names of the persons or

organizations that manage or will manage your activities or facilities, and how these managers were or

will be selected. Also, submit copies of any contracts, proposed contracts, or other agreements

regarding the provision of management services for your activities or facilities. Explain how the terms of

any contracts or other agreements were or will be negotiated, and explain how you determine you will

pay no more than fair market value for services.

Yes No

Note: Answer “Yes” if you manage or intend to manage your programs through your own employees or

by using volunteers. Answer “No” if you engage or intend to engage a separate organization or

independent contractor. Make sure your answer is consistent with the information provided in Part VIII,

line 7b.

Section II Establishment of Racially Nondiscriminatory Policy

Information required by Revenue Procedure 75-50.

Have you adopted a racially nondiscriminatory policy as to students in your organizing document,

bylaws, or by resolution of your governing body? If “Yes,” state where the policy can be found or supply

a copy of the policy. If “No,” you must adopt a nondiscriminatory policy as to students before submitting

this application. See Pub. 557.

Yes No

Do your brochures, application forms, advertisements, and catalogues dealing with student admissions,

programs, and scholarships contain a statement of your racially nondiscriminatory policy?

Yes No

a If “Yes,” attach a representative sample of each document.

If “No,” by checking the box to the right you agree that all future printed materials, including website

content, will contain the required nondiscriminatory policy statement.

▶

Have you published a notice of your nondiscriminatory policy in a newspaper of general circulation that

serves all racial segments of the community? See the instructions for specific requirements. If “No,”

explain.

Yes No

Does or will the organization (or any department or division within it) discriminate in any way on the basis

of race with respect to admissions; use of facilities or exercise of student privileges; faculty or

administrative staff; or scholarship or loan programs? If “Yes,” for any of the above, explain fully.

Yes No

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 15

Schedule B. Schools, Colleges, and Universities (Continued)

Complete the table below to show the racial composition for the current academic year and projected for the next academic

year, of: (a) the student body, (b) the faculty, and (c) the administrative staff. Provide actual numbers rather than percentages

for each racial category.

If you are not operational, submit an estimate based on the best information available (such as the racial composition of the

community served).

Racial Category

(a) Student Body (b) Faculty (c) Administrative Staff

Current Year

Next Year

Current Year

Next Year

Current Year

Next Year

Total

In the table below, provide the number and amount of loans and scholarships awarded to students enrolled by racial

categories.

Racial Category

Number of Loans Amount of Loans

Number of Scholarships Amount of Scholarships

Current Year

Next Year

Current Year

Next Year

Current Year

Next Year

Current Year

Next Year

Total

7 a

Attach a list of your incorporators, founders, board members, and donors of land or buildings, whether

individuals or organizations.

Do any of these individuals or organizations have an objective to maintain segregated public or private

school education? If “Yes,” explain.

Yes No

Will you maintain records according to the nondiscrimination provisions contained in Revenue Procedure

75-50? If “No,” explain. See instructions.

Yes No

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 16

Schedule C. Hospitals and Medical Research Organizations

Check the box if you are a hospital. See the instructions for a definition of the term “hospital,” which includes an

organization whose principal purpose or function is providing hospital or medical care. Complete Section I below.

Check the box if you are a medical research organization operated in conjunction with a hospital. See the instructions for

a definition of the term “medical research organization,” which refers to an organization whose principal purpose or

function is medical research and which is directly engaged in the continuous active conduct of medical research in

conjunction with a hospital. Complete Section II.

Section I Hospitals

1 a

Are all the doctors in the community eligible for staff privileges? If “No,” give the reasons why and

explain how the medical staff is selected.

Yes No

2 a

Do you or will you provide medical services to all individuals in your community who can pay for

themselves or have private health insurance? If “No,” explain.

Yes No

Do you or will you provide medical services to all individuals in your community who participate in

Medicare? If “No,” explain.

Yes No

Do you or will you provide medical services to all individuals in your community who participate in

Medicaid? If “No,” explain.

Yes No

Do you or will you require persons covered by Medicare or Medicaid to pay a deposit before receiving

services? If “Yes,” explain.

Yes No

Does the same deposit requirement, if any, apply to all other patients? If “No,” explain.

Yes No

4 a

Do you or will you maintain a full-time emergency room? If “No,” explain why you do not maintain a

full-time emergency room. Also, describe any emergency services that you provide.

Yes No

Do you have a policy on providing emergency services to persons without apparent means to pay? If

“Yes,” provide a copy of the policy.

Yes No

Do you have any arrangements with police, fire, and voluntary ambulance services for the delivery or

admission of emergency cases? If “Yes,” describe the arrangements, including whether they are written

or oral agreements. If written, submit copies of all such agreements.

Yes No

5 a

Do you provide for a portion of your services and facilities to be used for charity patients? If “Yes,”

answer 5b through 5e.

Yes No

Explain your policy regarding charity cases, including how you distinguish between charity care and bad

debts. Submit a copy of your written policy.

Provide data on your past experience in admitting charity patients, including amounts you expend for

treating charity care patients and types of services you provide to charity care patients.

Describe any arrangements you have with federal, state, or local governments or government agencies

for paying for the cost of treating charity care patients. Submit copies of any written agreements.

Do you provide services on a sliding fee schedule depending on financial ability to pay? If “Yes,” submit

your sliding fee schedule.

Yes No

6 a

Do you or will you carry on a formal program of medical training or medical research? If “Yes,” describe

such programs, including the type of programs offered, the scope of such programs, and affiliations with

other hospitals or medical care providers with which you carry on the medical training or research

programs.

Yes No

b Do you or will you carry on a formal program of community education? If “Yes,” describe such programs,

including the type of programs offered, the scope of such programs, and affiliation with other hospitals or

medical care providers with which you offer community education programs.

Yes No

7 Do you or will you provide office space to physicians carrying on their own medical practices? If “Yes,”

describe the criteria for who may use the space, explain the means used to determine that you are paid

at least fair market value, and submit representative lease agreements.

Yes No

Is your board of directors comprised of a majority of individuals who are representative of the community

you serve? Include a list of each board member’s name and business, financial, or professional

relationship with the hospital. Also, identify each board member who is representative of the community

and describe how that individual is a community representative.

Yes No

Do you participate in any joint ventures? If “Yes,” state your ownership percentage in each joint venture,

list your investment in each joint venture, describe the tax status of other participants in each joint

venture (including whether they are section 501(c)(3) organizations), describe the activities of each joint

venture, describe how you exercise control over the activities of each joint venture, and describe how

each joint venture furthers your exempt purposes. Also, submit copies of all agreements.

Yes No

Note: Make sure your answer is consistent with the information provided in Part VIII, line 8.

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 17

Schedule C. Hospitals and Medical Research Organizations (Continued)

Section I Hospitals (Continued)

10 Do you or will you manage your activities or facilities through your own employees or volunteers? If “No,”

attach a statement describing the activities that will be managed by others, the names of the persons or

organizations that manage or will manage your activities or facilities, and how these managers were or

will be selected. Also, submit copies of any contracts, proposed contracts, or other agreements

regarding the provision of management services for your activities or facilities. Explain how the terms of

any contracts or other agreements were or will be negotiated, and explain how you determine you will

pay no more than fair market value for services.

Yes No

Note: Answer “Yes” if you do manage or intend to manage your programs through your own employees

or by using volunteers. Answer “No” if you engage or intend to engage a separate organization or

independent contractor. Make sure your answer is consistent with the information provided in Part VIII,

line 7b.

Do you or will you offer recruitment incentives to physicians? If “Yes,” describe your recruitment

incentives and attach copies of all written recruitment incentive policies.

Yes No

Do you or will you lease equipment, assets, or office space from physicians who have a financial or

professional relationship with you? If “Yes,” explain how you establish a fair market value for the lease.

Yes No

Have you purchased medical practices, ambulatory surgery centers, or other business assets from

physicians or other persons with whom you have a business relationship, aside from the purchase? If

“Yes,” submit a copy of each purchase and sales contract and describe how you arrived at fair market

value, including copies of appraisals.

Yes No

Have you adopted a conflict of interest policy consistent with the sample health care organization

conflict of interest policy in Appendix A of the instructions? If “Yes,” submit a copy of the policy and

explain how the policy has been adopted, such as by resolution of your governing board. If “No,” explain

how you will avoid any conflicts of interest in your business dealings.

Yes No

Section II Medical Research Organizations

Name the hospitals with which you have a relationship and describe the relationship. Attach copies of

written agreements with each hospital that demonstrate continuing relationships between you and the

hospital(s).

Attach a schedule describing your present and proposed activities for the direct conduct of medical

research; describe the nature of the activities, and the amount of money that has been or will be spent in

carrying them out.

Attach a schedule of assets showing their fair market value and the portion of your assets directly

devoted to medical research.

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 18

Schedule D. Section 509(a)(3) Supporting Organizations

Section I Identifying Information About the Supported Organization(s)

State the names, addresses, and EINs of the supported organizations. If additional space is needed, attach a separate sheet.

Name Address EIN

Are all supported organizations listed in line 1 public charities under section 509(a)(1) or (2)? If “Yes,” go

to Section II. If “No,” go to line 3.

Yes No

3 Do the supported organizations have tax-exempt status under section 501(c)(4), 501(c)(5), or 501(c)(6)? Yes No

If “Yes,” for each 501(c)(4), (5), or (6) organization supported, provide the following financial information.

• Part IX-A. Statement of Revenues and Expenses, lines 1–13, and

• Part X, lines 6b(i), 6b(ii), and 7.

If “No,” attach a statement describing how each organization you support is a public charity under

section 509(a)(1) or (2).

Section II Relationship with Supported Organization(s)—Three Tests

To be classified as a supporting organization, an organization must meet one of three relationship tests.

Test 1: “Operated, supervised, or controlled by” one or more publicly supported organizations, or

Test 2: “Supervised or controlled in connection with” one or more publicly supported organizations, or

Test 3: “Operated in connection with” one or more publicly supported organizations.

1 Information to establish the “operated, supervised, or controlled by” relationship (Test 1)

Is a majority of your governing board or officers elected or appointed by the supported organization(s)?

If “Yes,” describe the process by which your governing board is appointed and elected; go to Section III.

If “No,” continue to line 2.

Yes No

2 Information to establish the “supervised or controlled in connection with” relationship (Test 2)

Does a majority of your governing board consist of individuals who also serve on the governing board of

the supported organization(s)? If “Yes,” describe the process by which your governing board is appointed

and elected; go to Section III. If “No,” go to line 3.

Yes No

3 Information to establish the “operated in connection with” responsiveness test (Test 3)

Are you a trust from which the named supported organization(s) can enforce and compel an accounting

under state law? If “Yes,” explain whether you advised the supported organization(s) in writing of these

rights and provide a copy of the written communication documenting this; go to Section II, line 5. If “No,”

go to line 4a.

Yes No

4 Information to establish the alternative “operated in connection with” responsiveness test (Test 3)

Do the officers, directors, trustees, or members of the supported organization(s) elect or appoint one or

more of your officers, directors, or trustees? If “Yes,” explain and provide documentation; go to line 4d,

below. If “No,” go to line 4b.

Yes No

Do one or more members of the governing body of the supported organization(s) also serve as your

officers, directors, or trustees or hold other important offices with respect to you? If “Yes,” explain and

provide documentation; go to line 4d, below. If “No,” go to line 4c.

Yes No

c Do your officers, directors, or trustees maintain a close and continuous working relationship with the

officers, directors, or trustees of the supported organization(s)? If “Yes,” explain and provide

documentation.

Yes No

d Do the supported organization(s) have a significant voice in your investment policies, in the making and

timing of grants, and in otherwise directing the use of your income or assets? If “Yes,” explain and

provide documentation.

Yes No

Describe and provide copies of written communications documenting how you made the supported

organization(s) aware of your supporting activities.

5 Information to establish the “operated in connection with” integral part test (Test 3)

Do you conduct activities that would otherwise be carried out by the supported organization(s)? If “Yes,”

explain and go to Section III. If “No,” continue to line 6a.

Yes No

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 19

Schedule D. Section 509(a)(3) Supporting Organizations (Continued)

Section II Relationship with Supported Organization(s)—Three Tests (Continued)

6 Information to establish the alternative “operated in connection with” integral part test (Test 3)

Do you distribute at least 85% of your annual net income to the supported organization(s)? If “Yes,” go

to line 6b. See instructions.

Yes No

If “No,” state the percentage of your income that you distribute to each supported organization. Also

explain how you ensure that the supported organization(s) are attentive to your operations.

b How much do you contribute annually to each supported organization? Attach a schedule.

What is the total annual revenue of each supported organization? If you need additional space, attach a

list.

Do you or the supported organization(s) earmark your funds for support of a particular program or

activity? If “Yes,” explain.

Yes No

7 a

Does your organizing document specify the supported organization(s) by name? If “Yes,” state the article

and paragraph number and go to Section III. If “No,” answer line 7b.

Yes No

Attach a statement describing whether there has been an historic and continuing relationship between

you and the supported organization(s).

Section III Organizational Test

1a If you met relationship Test 1 or Test 2 in Section II, your organizing document must specify the

supported organization(s) by name, or by naming a similar purpose or charitable class of beneficiaries. If

your organizing document complies with this requirement, answer “Yes.” If your organizing document

does not comply with this requirement, answer “No,” and see the instructions.

Yes No

If you met relationship Test 3 in Section II, your organizing document must generally specify the

supported organization(s) by name. If your organizing document complies with this requirement, answer

“Yes,” and go to Section IV. If your organizing document does not comply with this requirement, answer

“No,” and see the instructions.

Yes No

Section IV Disqualified Person Test

You do not qualify as a supporting organization if you are controlled directly or indirectly by one or more disqualified persons (as

defined in section 4946) other than foundation managers or one or more organizations that you support. Foundation managers who

are also disqualified persons for another reason are disqualified persons with respect to you.

Do any persons who are disqualified persons with respect to you, (except individuals who are

disqualified persons only because they are foundation managers), appoint any of your foundation

managers? If “Yes,” (1) describe the process by which disqualified persons appoint any of your

foundation managers, (2) provide the names of these disqualified persons and the foundation managers

they appoint, and (3) explain how control is vested over your operations (including assets and activities)

by persons other than disqualified persons.

Yes No

Do any persons who have a family or business relationship with any disqualified persons with respect to

you, (except individuals who are disqualified persons only because they are foundation managers),

appoint any of your foundation managers? If “Yes,” (1) describe the process by which individuals with a

family or business relationship with disqualified persons appoint any of your foundation managers,

(2) provide the names of these disqualified persons, the individuals with a family or business relationship

with disqualified persons, and the foundation managers appointed, and (3) explain how control is vested

over your operations (including assets and activities) in individuals other than disqualified persons.

Yes No

c Do any persons who are disqualified persons, (except individuals who are disqualified persons only

because they are foundation managers), have any influence regarding your operations, including your

assets or activities? If “Yes,” (1) provide the names of these disqualified persons, (2) explain how

influence is exerted over your operations (including assets and activities), and (3) explain how control is

vested over your operations (including assets and activities) by individuals other than disqualified

persons.

Yes No

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 20

Schedule E. Organizations Not Filing Form 1023 Within 27 Months of Formation

Schedule E is intended to determine whether you are eligible for tax exemption under section 501(c)(3) from the postmark date of your

application or from your date of incorporation or formation, whichever is earlier.

Are you a church, association of churches, or integrated auxiliary of a church? If “Yes,” complete

Schedule A and stop here. Do not complete the remainder of Schedule E.

Yes No

2 a

Are you a public charity with annual gross receipts that are normally $5,000 or less? If “Yes,” stop here.

Answer “No” if you are a private foundation, regardless of your gross receipts.

Yes No

If your gross receipts were normally more than $5,000, are you filing this application within 90 days from

the end of the tax year in which your gross receipts were normally more than $5,000? If “Yes,” stop here.

Yes No

3a Were you included as a subordinate in a group exemption application or letter? If “No,” go to line 4. Yes No

If you were included as a subordinate in a group exemption letter, are you filing this application within 27

months from the date you were notified by the organization holding the group exemption letter or the

Internal Revenue Service that you cease to be covered by the group exemption letter? If “Yes,” stop here.

Yes No

If you were included as a subordinate in a timely filed group exemption request that was denied, are you

filing this application within 27 months from the postmark date of the Internal Revenue Service final

adverse ruling letter? If “Yes,” stop here.

Yes No

Were you created on or before October 9, 1969? If “Yes,” stop here. Do not complete the remainder of

this schedule.

Yes No

If you answered “No” to lines 1 through 4, we cannot recognize you as tax exempt from your date of

formation unless you qualify for an extension of time to apply for exemption. Do you wish to request an

extension of time to apply to be recognized as exempt from the date you were formed? If “Yes,” attach a

statement explaining why you did not file this application within the 27-month period. Do not answer lines

6 or 7. If “No,” go to line 6a.

Yes No

6 a If you answered “No” to line 5, you can only be exempt under section 501(c)(3) from the postmark date of

this application. Therefore, do you want us to treat this application as a request for tax exemption from

the postmark date?

Yes No

Note: Be sure your ruling eligibility agrees with your answer to Part X, line 6.

Do you anticipate significant changes in your sources of support in the future? If “Yes,” complete line 7

below.

Yes No

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 21

Schedule E. Organizations Not Filing Form 1023 Within 27 Months of Formation (Continued)

Complete this item only if you answered “Yes” to line 6b. Include projected revenue for the first two full years following the

current tax year.

Type of Revenue Projected revenue for 2 years following current tax year

(a) From

(b) From

1 Gifts, grants, and contributions received (do not

include unusual grants)

Membership fees received

Gross investment income

4 Net unrelated business income

Taxes levied for your benefit

Value of services or facilities furnished by a

governmental unit without charge (not including

the value of services generally furnished to the

public without charge)

Any revenue not otherwise listed above or in lines

9–12 below (attach an itemized list)

Total of lines 1 through 7

Gross receipts from admissions, merchandise

sold, or services performed, or furnishing of

facilities in any activity that is related to your

exempt purposes (attach itemized list)

Total of lines 8 and 9

Net gain or loss on sale of capital assets

(attach an itemized list)

12 Unusual grants

13 Total revenue. Add lines 10 through 12

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 22

Schedule F. Homes for the Elderly or Handicapped and Low-Income Housing

Section I General Information About Your Housing

Describe the type of housing you provide.

Provide copies of any application forms you use for admission.

Explain how the public is made aware of your facility.

4 a Provide a description of each facility.

b What is the total number of residents each facility can accommodate?

c What is your current number of residents in each facility?

d Describe each facility in terms of whether residents rent or purchase housing from you.

Attach a sample copy of your residency or homeownership contract or agreement.

6 Do you participate in any joint ventures? If “Yes,” state your ownership percentage in each joint venture,

list your investment in each joint venture, describe the tax status of other participants in each joint

venture (including whether they are section 501(c)(3) organizations), describe the activities of each joint

venture, describe how you exercise control over the activities of each joint venture, and describe how

each joint venture furthers your exempt purposes. Also, submit copies of all joint venture agreements.

Yes No

Note: Make sure your answer is consistent with the information provided in Part VIII, line 8.

Do you or will you contract with another organization to develop, build, market, or finance your housing?

If “Yes,” explain how that entity is selected, explain how the terms of any contract(s) are negotiated at

arm’s length, and explain how you determine you will pay no more than fair market value for services.

Yes No

Note: Make sure your answer is consistent with the information provided in Part VIII, line 7a.

8 Do you or will you manage your activities or facilities through your own employees or volunteers? If “No,”

attach a statement describing the activities that will be managed by others, the names of the persons or

organizations that manage or will manage your activities or facilities, and how these managers were or

will be selected. Also, submit copies of any contracts, proposed contracts, or other agreements

regarding the provision of management services for your activities or facilities. Explain how the terms of

any contracts or other agreements were or will be negotiated, and explain how you determine you will

pay no more than fair market value for services.

Yes No

Note: Answer “Yes” if you do manage or intend to manage your programs through your own employees

or by using volunteers. Answer “No” if you engage or intend to engage a separate organization or

independent contractor. Make sure your answer is consistent with the information provided in Part VIII,

line 7b.

Do you participate in any government housing programs? If “Yes,” describe these programs.

Yes No

10 a

Do you own the facility? If “No,” describe any enforceable rights you possess to purchase the facility in

the future; go to line 10c. If “Yes,” answer line 10b.

Yes No

How did you acquire the facility? For example, did you develop it yourself, purchase a project, etc.

Attach all contracts, transfer agreements, or other documents connected with the acquisition of the

facility.

Do you lease the facility or the land on which it is located? If “Yes,” describe the parties to the lease(s)

and provide copies of all leases.

Yes No

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 23

Schedule F. Homes for the Elderly or Handicapped and Low-Income Housing (Continued)

Section II Homes for the Elderly or Handicapped

Do you provide housing for the elderly? If “Yes,” describe who qualifies for your housing in terms of age,

infirmity, or other criteria and explain how you select persons for your housing.

Yes No

Do you provide housing for the handicapped? If “Yes,” describe who qualifies for your housing in terms

of disability, income levels, or other criteria and explain how you select persons for your housing.

Yes No

2 a

Do you charge an entrance or founder’s fee? If “Yes,” describe what this charge covers, whether it is a

one-time fee, how the fee is determined, whether it is payable in a lump sum or on an installment basis,

whether it is refundable, and the circumstances, if any, under which it may be waived.

Yes No

Do you charge periodic fees or maintenance charges? If “Yes,” describe what these charges cover and

how they are determined.

Yes No

c Is your housing affordable to a significant segment of the elderly or handicapped persons in the

community? Identify your community. Also, if “Yes,” explain how you determine your housing is

affordable.

Yes No

3 a

Do you have an established policy concerning residents who become unable to pay their regular

charges? If “Yes,” describe your established policy.

Yes No

Do you have any arrangements with government welfare agencies or others to absorb all or part of the

cost of maintaining residents who become unable to pay their regular charges? If “Yes,” describe these

arrangements.

Yes No

Do you have arrangements for the healthcare needs of your residents? If “Yes,” describe these

arrangements.

Yes No

Are your facilities designed to meet the physical, emotional, recreational, social, religious, and/or other

similar needs of the elderly or handicapped? If “Yes,” describe these design features.

Yes No

Section III

Low-Income Housing

Do you provide low-income housing? If “Yes,” describe who qualifies for your housing in terms of

income levels or other criteria, and describe how you select persons for your housing.

Yes No

In addition to rent or mortgage payments, do residents pay periodic fees or maintenance charges? If

“Yes,” describe what these charges cover and how they are determined.

Yes No

3 a

Is your housing affordable to low income residents? If “Yes,” describe how your housing is made

affordable to low-income residents.

Yes No

Note: Revenue Procedure 96-32, 1996-1 C.B. 717, provides guidelines for providing low-income housing

that will be treated as charitable. (At least 75% of the units are occupied by low-income tenants or 40%

are occupied by tenants earning not more than 120% of the very low-income levels for the area.)

Do you impose any restrictions to make sure that your housing remains affordable to low-income

residents? If “Yes,” describe these restrictions.

Yes No

4 Do you provide social services to residents? If “Yes,” describe these services. Yes No

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 24

Schedule G. Successors to Other Organizations

1 a

Are you a successor to a for-profit organization? If “Yes,” explain the relationship with the

predecessor organization that resulted in your creation and complete line 1b.

Yes No

Explain why you took over the activities or assets of a for-profit organization or converted from for-profit

to nonprofit status.

2a Are you a successor to an organization other than a for-profit organization? Answer “Yes” if you have

taken or will take over the activities of another organization; or you have taken or will take over 25% or

more of the fair market value of the net assets of another organization. If “Yes,” explain the relationship

with the other organization that resulted in your creation.

Yes No

b Provide the tax status of the predecessor organization.

Did you or did an organization to which you are a successor previously apply for tax exemption under

section 501(c)(3) or any other section of the Code? If “Yes,” explain how the application was resolved.

Yes No

Was your prior tax exemption or the tax exemption of an organization to which you are a successor

revoked or suspended? If “Yes,” explain. Include a description of the corrections you made to

re-establish tax exemption.

Yes No

Explain why you took over the activities or assets of another organization.

3 Provide the name, last address, and EIN of the predecessor organization and describe its activities.

Name: EIN:

Address:

List the owners, partners, principal stockholders, officers, and governing board members of the predecessor organization.

Attach a separate sheet if additional space is needed.

Name Address

Share/Interest (If a for-profit)

Do or will any of the persons listed in line 4, maintain a working relationship with you? If “Yes,” describe

the relationship in detail and include copies of any agreements with any of these persons or with any

for-profit organizations in which these persons own more than a 35% interest.

Yes No

Were any assets transferred, whether by gift or sale, from the predecessor organization to you? If “Yes,”

provide a list of assets, indicate the value of each asset, explain how the value was determined, and

attach an appraisal, if available. For each asset listed, also explain if the transfer was by gift, sale, or

combination thereof.

Yes No

b Were any restrictions placed on the use or sale of the assets? If “Yes,” explain the restrictions.

Yes No

Provide a copy of the agreement(s) of sale or transfer.

7 Were any debts or liabilities transferred from the predecessor for-profit organization to you? Yes No

If “Yes,” provide a list of the debts or liabilities that were transferred to you, indicating the amount of

each, how the amount was determined, and the name of the person to whom the debt or liability is

owed.

8 Will you lease or rent any property or equipment previously owned or used by the predecessor for-profit

organization, or from persons listed in line 4, or from for-profit organizations in which these persons own

more than a 35% interest? If “Yes,” submit a copy of the lease or rental agreement(s). Indicate how the

lease or rental value of the property or equipment was determined.

Yes No

9 Will you lease or rent property or equipment to persons listed in line 4, or to for-profit organizations in

which these persons own more than a 35% interest? If “Yes,” attach a list of the property or equipment,

provide a copy of the lease or rental agreement(s), and indicate how the lease or rental value of the

property or equipment was determined.

Yes No

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 25

Schedule H. Organizations Providing Scholarships, Fellowships, Educational Loans, or Other Educational Grants

to Individuals and Private Foundations Requesting Advance Approval of Individual Grant Procedures

Section I Names of individual recipients are not required to be listed in Schedule H.

Public charities and private foundations complete lines 1a through 7 of this section. See the

instructions to Part X if you are not sure whether you are a public charity or a private foundation.

1 a Describe the types of educational grants you provide to individuals, such as scholarships, fellowships, loans, etc.

Describe the purpose and amount of your scholarships, fellowships, and other educational grants and loans that

you award.

c If you award educational loans, explain the terms of the loans (interest rate, length, forgiveness, etc.).

d Specify how your program is publicized.

e Provide copies of any solicitation or announcement materials.

Provide a sample copy of the application used.

2 Do you maintain case histories showing recipients of your scholarships, fellowships, educational loans, or

other educational grants, including names, addresses, purposes of awards, amount of each grant,

manner of selection, and relationship (if any) to officers, trustees, or donors of funds to you? If “No,” refer

to the instructions.

Yes No

Describe the specific criteria you use to determine who is eligible for your program. (For example, eligibility

selection criteria could consist of graduating high school students from a particular high school who will attend

college, writers of scholarly works about American history, etc.)

4 a

Describe the specific criteria you use to select recipients. (For example, specific selection criteria could consist of

prior academic performance, financial need, etc.)

b Describe how you determine the number of grants that will be made annually.

c Describe how you determine the amount of each of your grants.

Describe any requirement or condition that you impose on recipients to obtain, maintain, or qualify for renewal of a

grant. (For example, specific requirements or conditions could consist of attendance at a four-year college,

maintaining a certain grade point average, teaching in public school after graduation from college, etc.)

Describe your procedures for supervising the scholarships, fellowships, educational loans, or other educational

grants. Describe whether you obtain reports and grade transcripts from recipients, or you pay grants directly to a

school under an arrangement whereby the school will apply the grant funds only for enrolled students who are in

good standing. Also, describe your procedures for taking action if the terms of the award are violated.

Who is on the selection committee for the awards made under your program, including names of current

committee members, criteria for committee membership, and the method of replacing committee members?

7 Are relatives of members of the selection committee, or of your officers, directors, or substantial

contributors eligible for awards made under your program? If “Yes,” what measures are taken to ensure

unbiased selections?

Yes No

Note: If you are a private foundation, you are not permitted to provide educational grants to disqualified

persons. Disqualified persons include your substantial contributors and foundation managers and

certain family members of disqualified persons.

Section II

Private foundations complete lines 1a through 4f of this section. Public charities do not complete

this section.

1 a

If we determine that you are a private foundation, do you want this application to be

considered as a request for advance approval of grant making procedures?

Yes No N/A

b For which section(s) do you wish to be considered?

• 4945(g)(1)—Scholarship or fellowship grant to an individual for study at an educational institution

• 4945(g)(3)—Other grants, including loans, to an individual for travel, study, or other similar

purposes, to enhance a particular skill of the grantee or to produce a specific product

2 Do you represent that you will (1) arrange to receive and review grantee reports annually and

upon completion of the purpose for which the grant was awarded, (2) investigate diversions of

funds from their intended purposes, and (3) take all reasonable and appropriate steps to

recover diverted funds, ensure other grant funds held by a grantee are used for their intended

purposes, and withhold further payments to grantees until you obtain grantees’ assurances

that future diversions will not occur and that grantees will take extraordinary precautions to

prevent future diversions from occurring?

Yes No

3 Do you represent that you will maintain all records relating to individual grants, including

information obtained to evaluate grantees, identify whether a grantee is a disqualified person,

establish the amount and purpose of each grant, and establish that you undertook the

supervision and investigation of grants described in line 2?

Yes No

Form 1023 (Rev. 12-2017)

Name: EIN:

Page 26

Schedule H. Organizations Providing Scholarships, Fellowships, Educational Loans, or Other Educational Grants

to Individuals and Private Foundations Requesting Advance Approval of Individual Grant Procedures (Continued)

Section II

Private foundations complete lines 1a through 4f of this section. Public charities do not complete

this section. (Continued)

4 a Do you or will you award scholarships, fellowships, and educational loans to attend an

educational institution based on the status of an individual being an employee of a particular

employer? If “Yes,” complete lines 4b through 4f.

Yes No

b Will you comply with the seven conditions and either the percentage tests or facts and

circumstances test for scholarships, fellowships, and educational loans to attend an

educational institution as set forth in Revenue Procedures 76-47, 1976-2 C.B. 670, and 80-39,

1980-2 C.B. 772, which apply to inducement, selection committee, eligibility requirements,

objective basis of selection, employment, course of study, and other objectives? (See lines 4c,

4d, and 4e, regarding the percentage tests.)

Yes No

Do you or will you provide scholarships, fellowships, or educational loans to attend an

educational institution to employees of a particular employer?

Yes No N/A

If “Yes,” will you award grants to 10% or fewer of the eligible applicants who were actually

considered by the selection committee in selecting recipients of grants in that year as provided

by Revenue Procedures 76-47 and 80-39?

Yes No

Do you provide scholarships, fellowships, or educational loans to attend an educational

institution to children of employees of a particular employer?

Yes No N/A

If “Yes,” will you award grants to 25% or fewer of the eligible applicants who were actually

considered by the selection committee in selecting recipients of grants in that year as provided

by Revenue Procedures 76-47 and 80-39? If “No,” go to line 4e.

Yes No

If you provide scholarships, fellowships, or educational loans to attend an educational

institution to children of employees of a particular employer, will you award grants to 10% or

fewer of the number of employees’ children who can be shown to be eligible for grants

(whether or not they submitted an application) in that year, as provided by Revenue

Procedures 76-47 and 80-39?

Yes No N/A

If “Yes,” describe how you will determine who can be shown to be eligible for grants without

submitting an application, such as by obtaining written statements or other information about

the expectations of employees’ children to attend an educational institution. If “No,” go to line

4f.

Note: Statistical or sampling techniques are not acceptable. See Revenue Procedure

85-51, 1985-2 C.B. 717, for additional information.

f If you provide scholarships, fellowships, or educational loans to attend an educational

institution to children of employees of a particular employer without regard to either the 25%

limitation described in line 4d, or the 10% limitation described in line 4e, will you award grants

based on facts and circumstances that demonstrate that the grants will not be considered

compensation for past, present, or future services or otherwise provide a significant benefit to

the particular employer? If “Yes,” describe the facts and circumstances that you believe will

demonstrate that the grants are neither compensatory nor a significant benefit to the particular

employer. In your explanation, describe why you cannot satisfy either the 25% test described

in line 4d or the 10% test described in line 4e.

Yes No

Form 1023 (Rev. 12-2017)

Form 1023 Checklist

(Revised December 2017)

Application for Recognition of Exemption under Section 501(c)(3) of the

Internal Revenue Code

Note: Retain a copy of the completed Form 1023 in your permanent records. Refer to the General Instructions regarding

Public Inspection of approved applications.

Check each box to finish your application (Form 1023). Send this completed Checklist with your filled-in

application. If you have not answered all the items below, your application may be returned to you as

incomplete.

Assemble the application and materials in this order.

• Form 1023 Checklist

• Form 2848, Power of Attorney and Declaration of Representative (if filing)

• Form 8821, Tax Information Authorization (if filing)

• Expedite request (if requesting)

• Application (Form 1023 and Schedules A through H, as required)

• Articles of organization

• Amendments to articles of organization in chronological order

• Bylaws or other rules of operation and amendments

• Documentation of nondiscriminatory policy for schools, as required by Schedule B

• Form 5768, Election/Revocation of Election by an Eligible Section 501(c)(3) Organization To Make

Expenditures To Influence Legislation (if filing)

• All other attachments, including explanations, financial data, and printed materials or publications.

Label each page with name and EIN.

User fee payment placed in envelope on top of checklist. DO NOT STAPLE or otherwise attach your

check or money order to your application. Instead, just place it in the envelope.

Employer Identification Number (EIN)

Completed Parts I through XI of the application, including any requested information and any

required Schedules A through H.

• You must provide specific details about your past, present, and planned activities.

• Generalizations or failure to answer questions in the Form 1023 application will prevent us from

recognizing you as tax exempt.

• Describe your purposes and proposed activities in specific easily understood terms.

• Financial information should correspond with proposed activities.

Schedules. Submit only those schedules that apply to you and check either “Yes” or “No” below.

Schedule A

Yes

Schedule B Yes No

Schedule C Yes No

Schedule D Yes No

Schedule E Yes No

Schedule F Yes No

Schedule G Yes No

Schedule H Yes No

An exact copy of your complete articles of organization (creating document). Absence of the proper purpose

and dissolution clauses is the number one reason for delays in the issuance of determination letters.

• Location of Purpose Clause from Part III, line 1 (Page, Article and Paragraph Number)

• Location of Dissolution Clause from Part III, line 2b or 2c (Page, Article and Paragraph Number) or by

operation of state law

Signature of an officer, director, trustee, or other official who is authorized to sign the application.

• Signature at Part XI of Form 1023.

Your name on the application must be the same as your legal name as it appears in your articles of

organization.

Send completed Form 1023, user fee payment, and all other required information, to:

Internal Revenue Service

Attention: EO Determination Letters

Stop 31

P.O. Box 12192

Covington, KY 41012-0192

If you are using express mail or a delivery service, send Form 1023, user fee payment, and attachments to:

Internal Revenue Service

Attention: EO Determination Letters

Stop 31

201 West Rivercenter Boulevard

Covington, KY 41011

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