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)
d
Do you or will you record in writing the decision made by each individual who decided or voted on
compensation arrangements?
Yes No
e
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
f
Do you or will you record in writing both the information on which you relied to base your decision and its
source?
Yes No
g
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.
5a
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
b
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?
c
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.
6a
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
b
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
7a
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
b
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
8a
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.
e
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)