Form 1024-A
(January 2018)
Department of the Treasury
Internal Revenue Service
Application for Recognition of Exemption
Under Section 501(c)(4) of the Internal Revenue Code
Go to www.irs.gov/Form1024A for instructions and the latest information.
OMB No.1545-0057
Note: If exempt status
is approved, this
application will be open
for public inspection.
Complete Parts I–IX and submit Form 8718 (with payment of the appropriate user fee). Attach additional sheets if you need more
space to answer fully. Use the instructions to complete this application and for definitions of terms used in this form. For additional
help, call IRS Exempt Organizations Customer Account Services toll-free at 877-829-5500, or visit our website at www.irs.gov. If you
don’t submit the required information, we may return the application to you. A request for a determination under section 501(c)(4) is
optional. See instructions for additional information.
Don't include social security numbers on this form as it may be made public.
Part I
Identification of Applicant
1
Full name of organization (exactly as it appears in your organizing document)
2 c/o Name (if applicable)
3 Mailing address (Number and street) (see instructions)
City or town, state or country, and ZIP + 4
4 Employer Identification Number (EIN)
5
Month the annual accounting period ends
6 Primary contact (officer, director, trustee, or authorized representative)
a
Name:
b Phone:
c Fax: (optional)
7 Organization’s website:
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. Don't file this form unless you can check “Yes” on lines 1, 2, 3, or 4.
1
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
2
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. Include copies of any amendments to
your articles and be sure they show state filing certification. Also, if you adopted an operating agreement,
attach a copy, along with any amendments.
Yes No
3
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
4 Are you a trust? If “Yes,” attach a signed and dated copy of your trust agreement. Include signed and
dated copies of any amendments. If you are a trust, enter the date the trust was funded. (MM/DD/YYYY)
Yes No
5 Have you adopted bylaws? If “Yes,” attach a current copy showing date of adoption. If “No,” explain in
an attachment how your officers, directors, or trustees are selected.
Yes No
/ /
Part III
Narrative Description of Your Activities
Use an attachment to describe all of your past, present, and planned activities in a narrative (including the percentage of time and funds
spent on these activities). You may attach representative copies of newsletters, brochures, or similar documents for supporting details to
this narrative. Refer to the instructions for information that must be included in your description. Check this box to confirm that you
submitted a narrative attachment describing your activities.
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 69155Y
Form 1024-A (1-2018)
Form 1024-A (1-2018)
Name: EIN:
Page 2
Part IV Officers, Directors, Trustees, Employees, and Independent Contractors
1 List the names, titles, and mailing addresses for all of your officers, directors, and trustees. If additional space is needed,
attach a separate sheet.
Name Title Mailing address
The following “Yes” or “No” questions relate to all past, present, or planned relationships, transactions, or agreements with your
officers, directors, trustees, employees, members, and independent contractors.
2
Do you have a family or business relationship or agreement with any of your officers, directors, trustees,
employees, members, or independent contractors, or any entity they own or control, other than through
their position as your officer, director, trustee, employee, member, or independent contractor? If “Yes,”
identify in an attachment the individual and describe the relationship or agreement.
Yes No
3 a Do or will you pay any compensation to your officers, directors, trustees, employees, members, or
independent contractors? If “Yes,” answer lines 3b and 3c.
Yes No
b Do or will the individuals that approve compensation arrangements follow a conflict of interest policy?
If “No,” describe in an attachment how you set compensation that is reasonable.
Yes No
c
Do or will you compensate any of your officers, directors, trustees, employees, members, or independent
contractors through nonfixed payments, such as discretionary bonuses or revenue-based payments?
If “Yes,” describe in an attachment all nonfixed compensation agreements.
Yes No
Part V Your Specific Activities
The following “Yes” or “No” questions relate to all past, present, and planned activities you may conduct. See instructions.
1
Has the organization spent, or does it plan to spend, any money attempting to influence the selection,
nomination, election, or appointment of any person to any federal, state, or local public office or to an office
in a political organization? If “Yes,” explain in detail and list the amounts spent or to be spent in each case in
an attachment.
Yes No
2
Have you previously received a ruling or determination letter recognizing you (or any predecessor
organization) as exempt under section 501(c)(3) and later revoked that recognition of exemption on the
basis that you (or your predecessor) were carrying on propaganda or otherwise attempting to influence
legislation or on the basis that it engaged in political activity? If “Yes,” explain in an attachment.
Yes No
3
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,” explain in an attachment.
Yes No
4
Are you connected in any way with any other organization (for example, financial support on a continuing
basis; shared facilities or employees; same officers, directors, or trustees)? If “Yes,” explain in an attachment.
Yes No
5
Do you have members? If “Yes,” state in an attachment the qualifications necessary for membership, the
classes of membership and number of members in each class, and the voting rights or privileges received.
Yes No
6
Have you made, or do you plan on making, any distribution of property or surplus funds to shareholders or
members? If "Yes," explain in an attachment.
Yes No
7
Do you receive payments for services performed? If “Yes,” explain in an attachment the services
performed, income realized and expenses incurred, and the nature of benefits to the general public from
these activities.
Yes No
8 Do you lease property? If “Yes,” explain in an attachment. Include a description of the property, any
relationship between the applicant and the other party, and a copy of the lease agreement.
Yes No
9 Are you a homeowner’s association? If “Yes,” explain in an attachment whether access to any property
or facility you own or maintain is restricted in any way.
Yes No
10 Are you a local association of employees? If “Yes,” state in an attachment the name and address of each
employer whose employees are eligible for membership in the organization.
Yes No
11 Do you or will you make foreign grants or conduct activities in any foreign country or countries? If “Yes,”
describe those grants or activities in an attachment.
Yes No
Form 1024-A (1-2018)
Form 1024-A (1-2018)
Name: EIN:
Page 3
Part VI
Financial Data (see instructions for information you must provide) (attach statement regarding accounting
method, if necessary)
A. Statement of Revenues and Expenses
Revenues
Type of revenue or expense
Year: Year: Year:
1 Gifts, grants, and contributions received . . . . . . . . .
2 Membership fees received . . . . . . . . . . . . . .
3 Gross investment income . . . . . . . . . . . . . .
4 Net unrelated business income . . . . . . . . . . . .
5 Taxes levied for your benefit . . . . . . . . . . . . .
6 Value of services or facilities furnished by a governmental unit
without charge . . . . . . . . . . . . . . . . . .
7 Any revenue not otherwise listed above or in lines 9–11 below
(attach statement) . . . . . . . . . . . . . . . . .
8 Total of lines 1 through 7 . . . . . . . . . . . . . .
9 Gross receipts from any activity that is related to your exempt
purposes . . . . . . . . . . . . . . . . . . .
10 Total of lines 8 and 9 . . . . . . . . . . . . . . . .
11 Net gain or loss on sale of capital assets (attach statement) . . .
12 Total Revenue
Combine lines 10 and 11 . . . . . . . . . . . . . .
Expenses
13 Fundraising expenses (attach statement) . . . . . . . . .
14 Contributions, gifts, grants, and similar amounts paid out (attach
statement) . . . . . . . . . . . . . . . . . . .
15 Disbursements to or for the benefit of members (attach statement) .
16 Compensation of officers, directors, and trustees . . . . . .
17 Other salaries and wages . . . . . . . . . . . . . .
18 Occupancy . . . . . . . . . . . . . . . . . . .
19 Any expense not otherwise classified, such as program services
(attach statement) . . . . . . . . . . . . . . . . .
20
Total Expenses
Add lines 13 through 19 . . . . . . . . . . . . . . .
B. Balance Sheet (for your most recently completed tax year)
Year End
Assets
1 Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
2 Accounts receivable, net . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Inventories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Bonds and notes receivable (attach statement) . . . . . . . . . . . . . . . . . . 4
5 Corporate stocks (attach statement) . . . . . . . . . . . . . . . . . . . . . . 5
6 Loans receivable (attach statement) . . . . . . . . . . . . . . . . . . . . . . 6
7 Other investments (attach statement) . . . . . . . . . . . . . . . . . . . . . . 7
8 Depreciable and depletable assets (attach statement) . . . . . . . . . . . . . . . . 8
9 Land . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
10 Other assets (attach statement) . . . . . . . . . . . . . . . . . . . . . . . 10
11 Total assets (add lines 1 through 10) . . . . . . . . . . . . . . . . . . . . . . 11
Liabilities
12 Accounts payable . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
13 Contributions, gifts, grants, etc., payable . . . . . . . . . . . . . . . . . . . . 13
14 Mortgages and notes payable (attach statement) . . . . . . . . . . . . . . . . . . 14
15 Other liabilities (attach statement) . . . . . . . . . . . . . . . . . . . . . . . 15
16 Total liabilities (add lines 12 through 15) . . . . . . . . . . . . . . . . . . . . . 16
Fund Balances or Net Assets
17 Total fund balances or net assets . . . . . . . . . . . . . . . . . . . . . . .
17
18 Total liabilities and fund balances or net assets (add lines 16 and 17) . . . . . . . . . .
18
Form 1024-A (1-2018)
Form 1024-A (1-2018)
Name: EIN:
Page 4
Part VII Annual Filing Requirements (see instructions)
Certain organizations aren't required to file an information return. If you are granted tax-exemption, are you
claiming to be excused from filing an information return? If “Yes,” explain in an attachment.
Yes No
If you fail to file a required information return for three consecutive years, your exempt status will be revoked.
Part VIII Information Regarding Notification Requirement Under Section 506
Most organizations operating under section 501(c)(4) are required to notify the IRS that they are operating under section 501(c)(4)
within 60 days of formation by filing Form 8976, Notice of Intent to Operate Under Section 501(c)(4). If an organization doesn't submit
a timely notification, a penalty will be assessed. Submission of Form 1024-A doesn't satisfy the requirement to provide notice to the
IRS. See instructions for additional information regarding the notification requirement.
Part IX User Fee Information and Signature
You must include Form 8718 and the correct user fee payment with this application. If you don't submit the correct user fee, we won't
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 “User Fee” in the keyword box, or call Customer
Account Services at 877-829-5500 for current information. Also, attach Form 2848, if the application is signed by a person authorized
by power of attorney.
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
individual)
(Type or print name of signer)
(Date)
(Type or print title or authority of signer)
Form 1024-A (1-2018)
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