1023 Information

Step 1 of 16

Part I Identification

Full Name of Organization (exactly as it appears in your organizing document)

Care of Name (if applicable)

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

EIN

Month Tax Year Ends

Person to Contact if More Information is Needed (officer, director, trustee, or authorized representative

Contact Telephone Number

Fax Number (optional)

User Fee Submitted

Website

List the names, titles, and mailing addresses of your officers, directors, and/or trustees

Name

First Last

Title

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name

First Last

Title

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name

First Last

Title

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Part II Organizational Structure

You Must be a corporation, limit liability company (LLC), unincorporated association, or trust to be tax exempt.

Corporation

Limited Liability Company (LLC)

Unincorporated Association

Trust

Copy of your articles of incorporation (and any amendments) that shows proof of filing with the appropriate state agency

Max. file size: 256 MB.

Copy of your articles of organization (and any amendments) that shows proof of filing with the appropriate state agency. Also if you adopted an operating agreement, upload a copy along with any amendments.

Max. file size: 256 MB.

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

Max. file size: 256 MB.

Copy of your signed and dated trust agreement. Include signed and dated copies of any admendments.

Max. file size: 256 MB.

Date you Formed

MM slash DD slash YYYY

State (or U.S. territory) of incorporation or other formation. If you were formed under the laws of a foriegn country. State Foriegn Country

Have you adopted Bylaws?

Yes

Current copy of bylaws showing the date of adoption

Max. file size: 256 MB.

Explain how you select your officers, directors or trustees.

Are you a successor to another arganization?

Yes

Answer "yes" if you have taken or will take over the activities of another organization, you took 25% or more of the fair market value of the net assests of another organization, or if you were established upon the conversion of an organization from for-profit to nonprofit status

Part III Required Provisions in Your Organizing Document

Part III helps ensure that, when you submit this application, your organizing document contains the required provisions to meet the organizational test under section 501(c)(3). Part III Required Provisions in Your Organizing Document If you cannot check "Yes" 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. Remember to upload your original and amended organizing documents at the end of this form.

Does your organizing document limit your purposes to one or more exempt purposes within section 501(c)(3), such as charitable, religious, educational, and/or scientific purposes.

Yes

Section 501(c)(3) requires that your organizing document limit your purposes to one or more exempt purposes within section 501(c)(3), such as charitable, religious, educational, and/or scientific purposes. The following is an example of an acceptable purpose clause: The organization is organized exclusively for charitable, religious, educational, and scientific purposes under section 501(c)(3) of the Internal Revenue Code, or corresponding section of any future federal tax code

State specifically where your organizing document meets this requirement, such as a reference to a particular article or section in your organizing document (Page/Article/Paragraph)

Do you have Dissolution clauses?

Yes

Section 501(c)(3) requires that your organizing document provide that upon dissolution, your remaining assets be used exclusively for section 501(c) (3) exempt purposes, such as charitable, religious, educational, and/or scientific purposes. Depending on your entity type and the state in which you are formed, this requirement may be satisfied by operation of state law. The following is an example of an acceptable dissolution clause: Upon the dissolution of this organization, assets shall be distributed for one or more exempt purposes within the meaning of section 501(c)(3) of the Internal Revenue Code, or co

State specifically where your organizing document meets this requirement, such as a reference to a particular article or section in your organizing document (Page/Article/Paragraph) or indicate that you rely on state law.

Part IV Activities

Describe completely and in detail your past, present, and planned activities. Do not refer to or repeat the purposes in your organizing document.

For each past, present, or planned activity, include information that answers the following questions: a. What is the activity? b. Who conducts the activity? c. Where is the activity conducted? d. What percentage of your total time is allocated to the activity? e. How is the activity funded (for example, donations, fees, etc.) and what percentage of your overall expenses is allocated to this activity? f. How does the activity further your exempt purposes?

Enter the 3-character NTEE Code that best describes your activities.

Or check here if you want the IRS to select the NTEE Code that best describes your activities.

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

Yes

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.

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?

Yes

If "Yes," explain how these related individuals are eligible for goods, services, or funds.

Do you or will you support or oppose candidates in political campaigns in any way?

Yes

If "Yes," explain.

Do you or will you attempt to influence legislation? If "Yes," explain how you attempt to influence legislation

Yes

if "Yes," Explain

Did you or will you make an election to have your legislative activities measured by expenditures by filing Form 5768?

Yes

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.

Do you or will you publish, own, or have rights in music, literature, tapes, artworks, choreography, scientific discoveries, or other intellectual property?

Yes

If "Yes," 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

Do you or will you provide educational information to the general public on budgeting, personal finance, financial literacy, saving and spending practices, the sound use of consumer credit, and/or assist individuals and families with financial problems such as credit card debt and foreclosure by providing them with counseling?

Yes

If "Yes," explain.

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?

Yes

If "Yes," describe these procedures, including periodic reporting requirements, auditing grantees, site visits by your employees or compliance checks by impartial experts, etc., to verify that grant funds are being used appropriately.

Do you share board members or other key personnel with the recipient organization(s)?

Yes

If "Yes," identify the relationships

When you make grants, loans, or other distributions to foreign organizations, will you check the OFAC List of Specially Designated Nationals and Blocked Persons for names of individuals and entities with whom you are dealing to determine if they are included on the list?

Yes

Describe any other practices you will engage in to ensure that foreign expenditures or grants are not diverted to support terrorism or other non-charitable activities

Will you comply with all United States statutes, executive orders, and regulations that restrict or prohibit U.S. persons from engaging in transactions and dealings with designated countries, entities, or individuals, or otherwise engaging in activities in violation of economic sanctions administered by OFAC?

Yes

Will you acquire from OFAC the appropriate license and registration where necessary?

Yes

Do you or will you operate in a foreign country or countries?

Yes

If "Yes," name each foreign country and region within each country in which you do or will operate and describe your operations in each one.

When you conduct activities in foreign countries, will you check the OFAC List of Specially Designated Nationals and Blocked Persons for names of individuals and entities with whom you are dealing to determine if they are included on the list?

Yes

Describe any other practices you will engage in to ensure that foreign expenditures or grants are not diverted to support terrorism or other non-charitable activities

Yes

Will you acquire from OFAC the appropriate license and registration where necessary?

Yes

Are you a sponsoring organization that maintains one or more donor advised funds?

Yes

If yes, please provide a complete description of your program, including the specific advice that such donors may provide. Describe in detail the control you maintain (or will maintain) over the use of the funds.

Do you or will you operate a school?

Yes

If "Yes," complete Schedule B.

Is your principal purpose or function to provide hospital or medical care?

Yes

If "Yes," complete Schedule C.

Do you or will you provide low-income housing?

Yes

If "Yes," complete Schedule F.

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?

Yes

If "Yes," complete Schedule H - Section I.

Check any of the following fundraising activities that you will undertake (check all that apply

Website, mail, email, personal, and/or phone solicitations

Receive donations from another organization's website

Bingo

Foundation grant solicitations

Government grant solicitations

Other

We will not engage in fundraising activities.

Describe

Do you or will you engage in fundraising activities for other organizations?

Yes

If "Yes," describe these arrangements, including the names or descriptions of the organizations for which you raise fund

Part V Compensation and Other Financial Arrangements

Do you or will you compensate officers, directors, or trustees, or do or will you have highest compensated employees, or highest compensated independent contractors?

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Do or will you have any other practices you use to set reasonable compensation?

Yes

If "Yes," describe these practices.

Have you adopted a conflict of interest policy consistent with the sample conflict of interest policy in Appendix A to the instructions?

Yes

If you are a hospital, answer "Yes" if your conflict of interest policy includes provisions consistent with the additional healthcare related provisions in the sample document. If "No," describe the procedures you will follow to ensure that persons who have a conflict of interest will not have influence over setting their own compensation or regarding business deals with themselves

Do you or will you compensate any of your officers, directors, trustees, highest compensated employees, and highest compensated independent contractors through non-fixed payments, such as discretionary bonuses or revenue-based payments

Yes

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

Do you or will you purchase or sell any goods, services, or assets from or to: (i) any of your officers, directors, or trustees; (ii) any family of any of your officers, directors, or trustees; (iii) any organizations 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; (iv) your highest compensated employees; or (v) your highest compensated independent contractors?

Yes

If "Yes," describe any such transactions that you made or intend to make, with whom you make or will make such transactions, how the terms are or will be negotiated at arm's length, and how you determine you pay no more than fair market value or you are paid at least fair market value

Do you or will you have any leases, contracts, loans, or other agreements with: (i) your officers, directors, or trustees; (ii) any family of any of your officers, directors, or trustees; (iii) any organizations 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; (iv) your highest compensated employees; or (v) your highest compensated independent contractors?

Yes

If "Yes," describe any written or oral arrangements that you made or intend to make, with whom you have or will have such arrangements, how the terms are or will be negotiated at arm's length, and how you determine you pay no more than fair market value or you are paid at least fair market value

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

Yes

If "Yes," describe each facility, the role of the other organization, and any business or family relationship between the organization and your officers, directors, or trustees. Explain how that entity is selected, how the terms of any contract(s) are negotiated at arm's length, and how you determine you will pay no more than fair market value for services

Does or will someone other than your own employees or volunteers manage your activities or facilities?

Yes

If "Yes," describe the activities or facilities that will be managed by others, the names of the persons or organizations that manage or will manage your activities or facilities, and any business or family relationship between the organization and your officers, directors, or trustees. Explain how these managers were or will be selected, how the terms of any contracts or other agreements were or will be negotiated, and how you determine you will pay no more than fair market value for services.

Do you participate in any joint ventures, including partnerships or limited liability companies treated as partnerships, in which you share profits and losses with partners?

Yes

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.

Part VI Financial Data

Select the option that best describes you to determine the years of revenues and expenses you need to provide.

You completed less than one tax year

You completed at least one tax year but fewer than five.

You completed five or more tax years.

Provide a total of three years of financial information (including the current year and two future years of reasonable and good faith projections of your future finances) in the following Statement of Revenues and Expenses

Provide a total of four years financial information (including the current year and three years of actual financial information or reasonable and good faith projections of your future finances) in the following Statement of Revenues and Expenses

Provide financial information for your five most recent tax years (including the current year) in the following Statement of Revenues and Expenses

Current Tax Year

Type of revenue

From year

To year

1. Gifts, grants, and contributions received (do not include unusual grants)

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 (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 (provide an itemized list below furnished to the public without charge)

8. Total of 1-7

9. Gross receipts from admissions, merchandise sold or services performed, or furnishing of facilities in any activity that is related to your exempt purposes (provide an itemized list below

10. Total of 8-9

11. Net gain or loss on sale of capital assets (provide an itemized list below)

12. Unusual grants (provide an itemized list below)

13. Total Revenue (10-12)

Current Tax Year

Type of Expense

14 Fundraising expenses

15. Contributions, gifts, grants, and similar amounts paid out (provide an itemized list below)

16. Disbursements to or for the benefit of members (provide an itemized list below)

17. 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

23. Any expense not otherwise classified, such as program services (provide an itemized list below)

24. Total Expenses (add lines 14 through 23)

Past Tax Year 1 or Succeeding Year 1

Type of revenue

From Year

To year

1. Gifts, grants, and contributions received (do not include unusual grants)

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 (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 (provide an itemized list below)

8. Total of lines 1 through 7

9. Gross receipts from admissions, merchandise sold or services performed, or furnishing of facilities in any activity that is related to your exempt purposes (provide an itemized list below)

10. Total of lines 8 and 9

11. Net gain or loss on sale of capital assets (provide an itemized list below)

12. Unusual grants (provide an itemized list below)

13. Total Revenue (add lines 10 through 12)

Past Tax Year 1 or Succeeding Year 1

Type of expense

14. Fundraising expenses

15. Contributions, gifts, grants, and similar amounts paid out (provide an itemized list below)

16. Disbursements to or for the benefit of members (provide an itemized list below

17. 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

23. Any expense not otherwise classified, such as program services (provide an itemized list below)

24. Total Expenses (add lines 14 through 23)

Past Tax Year 2 or Succeeding Year 2

Type of Revenue

From Year

To Year

1. Gifts, grants, and contributions received (do not include unusual grants)

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 (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 (provide an itemized list below)

8. Total of lines 1 through 7

9. Gross receipts from admissions, merchandise sold or services performed, or furnishing of facilities in any activity that is related to your exempt purposes (provide an itemized list below)

10. Total of lines 8 and 9

11. Net gain or loss on sale of capital assets (provide an itemized list below

12. Unusual grants (provide an itemized list below)

13. Total Revenue (add lines 10 through 12)

Past Tax Year 2 or Succeeding Year 2

Type of Expense

14. Fundraising expenses

15. Contributions, gifts, grants, and similar amounts paid out (provide an itemized list below)

16. Disbursements to or for the benefit of members (provide an itemized list below)

17. 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

23. Any expense not otherwise classified, such as program services (provide an itemized list at below)

24. Total Expenses (add lines 14 through 23)

Past Tax Year 3

From Year

To Year

1. Gifts, grants, and contributions received (do not include unusual grants)

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 (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 (provide an itemized list below)

8. Total of lines 1 through 7

9. Gross receipts from admissions, merchandise sold or services performed, or furnishing of facilities in any activity that is related to your exempt purposes (provide an itemized list below)

10. Total of lines 8 and 9

11. Net gain or loss on sale of capital assets (provide an itemized list below)

12. Unusual grants (provide an itemized list below)

13. Total Revenue (add lines 10 through 12)

Past Tax Year 3

Type of Expense

14. Fundraising expenses

15. Contributions, gifts, grants, and similar amounts paid out (provide an itemized list below)

16. Disbursements to or for the benefit of members (provide an itemized list below)

17. 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

23. Any expense not otherwise classified, such as program services (provide an itemized list below)

24. Total Expenses (add lines 14 through 23)

Past Tax Year 4

Type of Revenue

From Year

To Year

1. Gifts, grants, and contributions received (do not include unusual grants)

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 (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 (provide an itemized list below)

8. Total of lines 1 through 7

9. Gross receipts from admissions, merchandise sold or services performed, or furnishing of facilities in any activity that is related to your exempt purposes (provide an itemized list below

10. Total of lines 8 and 9

11. Net gain or loss on sale of capital assets (provide an itemized list below)

12. Unusual grants (provide an itemized list below)

13. Total Revenue (add lines 10 through 12)

Past Tax Year 4

Type of Expense

14. Fundraising expenses

15. Contributions, gifts, grants, and similar amounts paid out (provide an itemized list below)

16. Disbursements to or for the benefit of members (provide an itemized list below

17. 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

23. Any expense not otherwise classified, such as program services (provide an itemized list below)

24. Total Expenses (add lines 14 through 23)

25. Itemized financial data

Part VI Cont.

Balance Sheet

Assets

Balance Sheet (for your most recently completed tax year) Year End:

1. Cash

2. Accounts receivable, net

3. Inventories

4. Bonds and notes receivable (provide an itemized list below)

5. Corporate stocks (provide an itemized list below)

6. Loans receivable (provide an itemized list below)

7. Other investments (provide an itemized list below)

8. Depreciable assets (provide an itemized list below)

9. Land

10. Other assets (provide an itemized list below)

11. Total Assets (add lines 1 through 10)

Liabilities

12. Accounts payable

13. Contributions, gifts, grants, etc. payable

14. Mortgages and notes payable (provide an itemized list below)

15. Other liabilities (provide an itemized list below)

16. Total Liabilities (add lines 12 through 15)

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)

19. Itemized financial data

Part VII Foundation Classification

Select the foundation classification you are requesting from the list below.

You are described in 509(a)(1) and 170(b)(1)(A)(vi) as 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

You are described in 509(a)(2) as 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)

You are described in 509(a)(1) and 170(b)(1)(A)(i) as a church or a convention or association of churches. Complete Schedule A.

You are described in 509(a)(1) and 170(b)(1)(A)(ii) as a school. Complete Schedule B

You are described in 509(a)(1) and 170(b)(1)(A)(iii) as a hospital, a cooperative hospital service organization, or a medical research organization operated in conjunction with a hospital. Complete Schedule C.

You are described in 509(a)(1) and 170(b)(1)(A)(iv) as an organization operated for the benefit of a college or university that is owned or operated by a governmental unit.

You are described in 509(a)(1) and 170(b)(1)(A)(ix) as an agricultural research organization directly engaged in the continuous active conduct of agricultural research in conjunction with a college or university

You are described in 509(a)(3) as an organization supporting either one or more organizations described in 509(a)(1) or 509(a) (2) or a publicly supported section 501(c)(4), (5), or (6) organization. Complete Schedule D

You are described in 509(a)(4) as an organization organized and operated exclusively for testing for public safety.

You are a publicly supported organization and would like the IRS to decide your correct classification.

You are a private foundation.

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 this box to confirm that your organizing document includes these provisions or you rely on state law.

Yes

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 - Section II.

Yes

Are you a private operating foundation?

Yes

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

Describe how you meet the requirements for private operating foundation status, including how you meet the income test and either the assets test, the endowment test, or the support test. If you've been in existence for less than one year, describe how you are likely to satisfy the requirements for private operating foundation status.

If you have been in existence more than 5 years, you must confirm your public support status. To confirm your qualification as a public charity described in 509(a)(1) and 170(b)(1)(A)(vi) in existence for five or more tax years, you must have received one-third or more of your total support from governmental agencies, contributions from the general public, and contributions or grants from other public charities; or 10% or more of your total support from governmental agencies, contributions from the general public, and contributions or grants from other public charities and the facts and circumstances indicate you are a publicly supported organization. Calculate whether you meet this support test for your most recent five-year period

Did you receive contributions from any person, company, or organization whose gifts totaled more than the 2% amount of line 8 in Part VI-A?

Yes

If "Yes," identify each person, company, or organization by letter (A, B, C, etc.) and indicate the amount contributed by each. Keep a list showing the name of and amount contributed by each of these donors for your records

Based on your calculations, did you receive at least one-third of your support from public sources or did you normally receive at least 10 percent of your support from public sources and you have other characteristics of a publicly supported organization?

Yes

If you have been in existence more than 5 years, you must confirm your public support status. To confirm your qualification as a public charity described in 509(a)(2) in existence for five or more tax years, you must have normally received more than one-third of your support from contributions, membership fees, and gross receipts from activities related to your exempt functions, or a combination of these sources, and not more than one-third of your support from gross investment income and net unrelated business income. Calculate whether you meet this support test for your most recent five-year period.

Did you receive amounts from any disqualified persons?

Yes

If "Yes," identify each disqualified person by letter (A, B, C, etc.) and indicate the amount contributed by each. Keep a list showing the name of and amount contributed by each of these donors for your records

Did you receive amounts from individuals or organizations other than disqualified persons that exceeded the greater of $5,000 or 1% of the amount on line 10 of Part VI-A Statement of Revenues and Expenses?

Yes

if "Yes," identify each individual or organization by letter (A, B, C, etc.) and indicate the amount contributed by each. Keep a list showing the name of and amount contributed by each of these donors for your records.

Based on your calculations, did you normally receive more than one-third of your support from a combination of gifts, grants, contributions, membership fees, and gross receipts (from permitted sources) from activities related to your exempt functions and normally receive not more than one-third of your support from investment income and unrelated business taxable income?

Yes

Part VIII Effective Date

In general, a determination letter recognizing exemption of an organization described in section 501(c)(3) is effective as of the date of formation of an organization if: (1) its purposes and activities prior to the date of the determination letter have been consistent with the requirements for exemption; and (2) it has filed an application for recognition of exemption within 27 months from the end of the month in which it was organized.

Are you submitting this application within 27 months of the end of the month in which you were legally formed?

Yes

If "No," complete Schedule E.

Part IX Annual Filing Requirements

If you fail to file a required information return or notice for three consecutive years, your exempt status will be automatically revoked.

Certain organizations are not required to file annual information returns or notices (Form 990, Form 990-EZ, or Form 990-N, e-Postcard). If you are granted tax-exemption, are you claiming to be excused from filing Form 990, Form 990-EZ, or Form 990-N?

Yes

If "Yes," are you claiming you are excepted from filing because you are:

A church or association of churches

An integrated auxiliary (such as a men's or women's organization, religious school, mission society, or religious group)

A school below college level affiliated with a church or operated by a religious order

A mission society (other than a section 509(a)(3) supporting organization) sponsored by, or affiliated with, one or more churches or church denominations, if more than half of the society's activities are conducted in, or directed at, persons in foreign countries

An affiliate of a governmental unit that meets the requirements of Revenue Procedure 95-48, 1995-2 C.B. 418 (other than a section 509(a)(3) supporting organization)

Other

Describe

Part X Signature

Declaration

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, and to the best of my knowledge it is true, correct, and complete.

Signature

Title

Date

MM slash DD slash YYYY

Schedule A. Churches

Do you have a written creed, statement of faith, or summary of beliefs?

Yes

If "Yes," describe your written creed, statement of faith, or summary of beliefs

Do you have a literature of your own?

Yes

If "Yes," describe your literature.

Do you have a formal code of doctrine and discipline?

Yes

If "Yes," describe your code of doctrine and discipline.

Describe your religious hierarchy or ecclesiastical government.

Are you part of a group of churches with similar beliefs and structures?

Yes

if "Yes," explain

Do you have a form of worship?

Yes

If "Yes," describe your form of worship.

Do you have regularly scheduled religious services?

Yes

If "Yes," describe the nature of the services.

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

Do you have an established place of worship?

Yes

If "Yes," describe your established place of worship or where you meet to hold regularly scheduled religious services.

Do you have an established congregation or other regular membership group?

Yes

How many members do you have?

Do you have a process by which an individual becomes a member?

Yes

If "Yes," describe the process

Do your members have voting rights, rights to participate in religious functions, or other rights?

Yes

If "Yes," describe the rights your members have.

May your members be associated with another denomination or church?

Yes

Are all of your members part of the same family?

Yes

Do you conduct baptisms, weddings, funerals, or other religious rites?

Yes

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

Yes

Do you have ministers or religious leaders?

Yes

If "Yes," describe these roles and explain whether the ministers or religious leaders are ordained, commissioned, or licensed after a prescribed course of study.

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

Yes

Do you ordain, commission, or license ministers or religious leaders?

Yes

If "Yes," describe the requirements for ordination, commission, or licensure.

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

Yes

If "Yes," explain.

Schedule B. Schools, Colleges, and Universities

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?

Yes

Is the primary function of your school the presentation of formal instruction?

Yes

Select the best description(s) of your school:

Elementary school

Secondary school

Charter school

College or university

Technical school

Other

Describe

Are you a public school because you are operated by a state or subdivision of a state or operated wholly or predominantly from government funds or property?

Yes

If "Yes," explain how you are operated by a state or subdivision of a state. Do not complete the remainder of Schedule B.

Were you formed or substantially expanded at the time of public school desegregation in the school district or county in which you are located?

Yes

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

Yes

If "Yes," explain

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

Yes

If "Yes," explain

Information Required by Revenue Procedure 75-50 as Modified by Revenue Procedure 2019-22

Have you adopted a racially nondiscriminatory policy as to students in your organizing document, bylaws, or by resolution of your governing body?

Yes

State where the policy is located or if adopted by resolution of your governing body.

Do your brochures, application forms, advertisements, and catalogues dealing with student admissions, programs, and scholarships contain a statement of your racially nondiscriminatory policy?

Yes

By checking this box, you agree that all future printed materials, including website content, will contain the required nondiscriminatory policy statement.

Yes

Have you made your racially nondiscriminatory policy known to all segments of the general community you serve by: a) publishing a notice of your policy in a newspaper of general circulation that serves all racial segments of the community; b) publicizing your policy over broadcast media in a way that is reasonably expected to be effective; or c) displaying a notice of your policy at all times on your primary, publicly accessible internet home page in a manner reasonably expected to be noticed by visitors to the homepage?

Yes

By checking this box, you agree that you will publicize your nondiscriminatory policy in a way that meets the requirements of Revenue Procedure 75-50, 1975-2 C.B. 587, as modified by Revenue Procedure 2019-22, I.R.B. 1260.

Yes

Do or will you (or any department or division of your organization) 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?

Yes

If "Yes," for any of the above, explain fully

Complete the table below to show the racial composition for the current academic year and projected for the next academic year. If you are not operational, submit an estimate based on the best information available (such as the racial composition of the community you serve). For each racial category, enter the number of (a) students, (b) faculty, and (c) administrative staff. Provide actual numbers rather than percentages for each racial category.

Student Body

Racial Category

Current Year

Next Year

Faculty

Racial Category

Current Year

Next Year

Administrative Staff

Racial Category

Current Year

Next Year

In the table below, enter the number and amount of loans and scholarships awarded to enrolled students by racial categories. Provide actual numbers rather than percentages for each racial category

Check here if you will not provide any loans or scholarships to students.

We will not provide Scholarships

Number of Loans

Racial Category

Current Year

Next Year

Amount of Loans

Racial Category

Current Year

Next Year

Number of Scholarships

Racial Category

Current Year

Next Year

Amount of Scholarships

Racial Category

Current Year

Next Year

List your incorporators, founders, board members, and donors of land or buildings, whether individuals or organizations.

Do any of your incorporators, founders, board members, and donors of land or buildings, whether individuals or organizations, have an objective to maintain segregated public or private school education?

Yes

If "Yes," explain.

Will you maintain records according to the nondiscrimination provisions contained in Revenue Procedure 75-50?

Yes

If "No," explain.

Schedule C. Hospitals and Medical Research Organizations

Are you a medical research organization (an organization whose principal purpose or function is medical research and which is directly engaged in the continuous active conduct of medical research) operated in conjunction with a hospital?

Yes

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

List your assets showing their fair market value and the portion of your assets directly devoted to medical research.

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

Yes

If "Yes" explain

Do not complete the remainder of Schedule C.

Are all the doctors in the community eligible for staff privileges?

Yes

If "No," give the reasons why and explain how the medical staff is selected.

Do you or will you maintain a full-time emergency room?

Yes

Are you a specialty hospital or would emergency services be duplicative based on your region or locality?

Yes

Do you provide free or below cost services?

Yes

If "Yes," describe your policy for determining when and to whom you provide these services and how these services promote the organization's benefit to the community.

Do you or will you carry on a formal program of medical training or medical research?

Yes

If "Yes," describe such programs, No 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

Do you or will you carry on a formal program of community education?

Yes

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.

Is your board of directors composed of a majority of individuals who are representative of the community you serve, or do you operate under a parent organization whose board of directors is composed of a majority of individuals who are representative of the community you serve?

Yes

List 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. If you operate under a parent organization whose board of directors is not composed of a majority of individuals who are representative of the community you serve, provide the requested information for your parent's board of directors as well.

Do you operate a facility which is required by a state to be licensed, registered, or similarly recognized as a hospital?

Yes

If "No," do not complete the rest of Schedule C.

Do you conduct a community health needs assessment (CHNA) at least once every three years and adopt an implementation strategy to meet the community health needs identified in the assessment as required by section 501(r)(3)?

Yes

If "No," explain.

Do you have a written financial assistance policy (FAP) and a written policy relating to emergency medical care as required by section 501(r)(4)?

Yes

If "No," explain.

Do you both (1) limit amounts charged for emergency or other medically necessary care provided to individuals eligible for assistance under your FAP to not more than amounts generally billed to individuals who have insurance covering such care, and (2) prohibit use of gross charges as required by section 501(r)(5)?

Yes

If "No," explain.

Do you make reasonable efforts to determine whether an individual is FAP-eligible before engaging in extraordinary collection actions as required by section 501(r)(6)?

Yes

If "No," explain.

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

List the names, addresses, and EINs of the organizations you support.

Are all your supported organizations public charities under section 509(a)(1) or (2)?

Yes

Are your supported organizations tax exempt under section 501(c)(4), 501(c)(5), or 501(c)(6) and do your supported organizations meet the public support test under section 509(a)(2)?

Yes

If "No," explain how each organization you support is a public charity under section 509(a)(1) or 509(a)(2).

Which of the following describes your relationship with your supported organization(s)?

A majority of your governing board or officers are elected or appointed by your supported organization(s). (Type I supporting organization)

Your control or management is vested in the same persons who control or manage your supported organization(s). (Type II supporting organization)

One or more of your officers, directors, or trustees are elected or appointed by the officers, directors, trustees, or membership of your supported organization(s), or one or more of your officers, directors, trustees, or other important office holders, are also members of the governing body of your supported organization(s), or your officers, directors, or trustees maintain a close and continuous working relationship with the officers, directors, or trustees of your supported organization(s). (Type III supporting organization)

Describe how your governing board and officers are selected. If you are a Type III organization, also describe how your officers, directors, or trustees maintain a close and continuous working relationship with the officers, directors, or trustees of your supported organization

Do any persons who are disqualified persons (except individuals who are disqualified persons only because they are foundation managers) with respect to you or persons who have a family or business relationship with any disqualified persons appoint any of your foundation managers?

Yes

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.

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?

Yes

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.

Does your organizing document specify your supported organization(s) by name?

Yes

If "Yes" and you selected Type I above, continue. If "Yes," and you selected Type II, do not complete the rest of Schedule D. If "No" and you selected Type III above, amend your organizing document to specify your supported organization(s) by name or you will not meet the organizational test and need to reconsider your requested public charity classification; then continue.

Does your organizing document name a similar purpose or charitable class of beneficiaries as to your supported organization(s)? .

Yes

If "No," amend your organizing document to specify your supported organization(s) by name, purpose, or class or you will not meet the organizational test and need to reconsider your requested public charity classification. If you selected Type II above, do not complete the rest of Schedule D.

Do you or will you receive contributions from any person who alone, or combined with family members or an entity at least 35% controlled by that person, controls any of your supported organizations, or will you receive contributions from any family member of, or an entity at least 35% controlled by, any person who controls any of your supported organizations?

Yes

If "Yes," explain.

If you selected Type I above, do not complete the rest of Schedule D.

Do the officers, directors, or trustees of your supported organization have a significant voice in your investment policies, the timing and making of grants, the selection of grant recipients, and in otherwise directing the use of your income or assets?

Yes

If "Yes," explain.

In each taxable year, do you or will you provide each of your supported organizations with (a) a written notice addressed to a principal officer of the supported organization describing the type and amount of all of the support you provided to the supported organization during the immediately preceding taxable year, (b) a copy of your most recently filed Form 990- series return or notice, and (c) a copy of your governing documents?

Yes

If 'No,' explain.

Do you exercise a substantial degree of direction over the policies, programs, and activities of your supported organization(s) and appoint or elect (directly or indirectly) a majority of the officers, directors, or trustees of your supported organization(s)?

Yes

If "Yes," explain.

Do substantially all of your activities directly further the exempt purposes of one or more supported organizations to which you are responsive by performing the functions of, or carrying out the purposes of, such supported organization(s) and but for your involvement would normally be engaged in by such supported organization(s)

Yes

If "Yes," explain and do not complete the rest of Schedule D.

Do you distribute at least 85% of your annual net income or 3.5% of the aggregate fair market value of all of your nonexempt-use assets (whichever is greater) to your supported organization(s)?

Yes

If "No," explain.

How much do you contribute annually to each supported organization?

What is the total annual revenue of each supported organization?

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

Yes

If "Yes," explain.

Schedule E. Effective Date

Are you applying for reinstatement of exemption after being automatically revoked for failure to file required returns or notices for three consecutive years?

Yes

Revenue Procedure 2014-11, 2014-1 C.B. 411, provides procedures for reinstating your tax-exempt status. Select the section of Revenue Procedure 2014-11 under which you want us to consider your reinstatement request.

Section 4. You are seeking retroactive reinstatement under section 4 of Revenue Procedure 2014-11. By selecting this line, you attest that you meet the specified requirements of section 4, that your failure to file was not intentional, and that you have put in place procedures to file required returns or notices in the future. Do not complete the rest of Schedule E

Section 5. You are seeking retroactive reinstatement under section 5 of Revenue Procedure 2014-11. By selecting this line, you attest that you meet the specified requirements of section 5, that you have filed required annual returns, that your failure to file was not intentional, and that you have put in place procedures to file required returns or notices in the future.

Section 6. You are seeking retroactive reinstatement under section 6 of Revenue Procedure 2014-11. By selecting this line, you attest that you meet the specified requirements of section 6, that you have filed required annual returns, that your failure to file was not intentional, and that you have put in place procedures to file required returns or notices in the future.

Section 7. You are seeking reinstatement under section 7 of Revenue Procedure 2014-11, effective the date you are filling this application. Do not complete the rest of Schedule E.

Describe how you exercised ordinary business care and prudence in determining and attempting to comply with your filing requirements in at least one of the three years of revocation and the steps you have taken or will take to avoid or mitigate future failures to file timely returns or notices. Do not complete the rest of Schedule E.

Describe how you exercised ordinary business care and prudence in determining and attempting to comply with your filing requirements in each of the three years of revocation and the steps you have taken or will take to avoid or mitigate future failures to file timely returns or notices. Do not complete the rest of Schedule E.

Generally, if you did not file Form 1023 within 27 months of formation, the effective date of your exempt status will be the date you filed Form 1023 (submission date). Requests for an earlier effective date may be granted when there is evidence to establish you acted reasonably and in good faith and the grant of relief will not prejudice the interests of the government

Check this box if you accept the submission date as the effective date of your exempt status. Do not complete the rest of Schedule E.

Check this box if you are requesting an earlier effective date than the submission date

Explain why you did not file Form 1023 within 27 months of formation, how you acted reasonably and in good faith, and how granting an earlier effective date will not prejudice the interests of the Government.

You may want to include the events that led to the failure to timely file Form 1023 and to the discovery of the failure, any reliance on the advice of a qualified tax professional and a description of the engagement and responsibilities of the professional as well as the extent to which you relied on the professional, a comparison of (1) what your aggregate tax liability would be if you had filed this application within the 27-month period with (2) what your aggregate liability would be if you were exempt as of your formation date, or any other information you believe will support your request for relief.

Schedule F. Low-Income Housing

Describe each facility including the type of facility, whether you own or lease the facility, how many residents it can accommodate, the current number of residents, and whether the residents purchase or rent housing from you.

Describe who qualifies for your housing in terms of income levels or other criteria and explain how you select residents

Do you meet the safe harbor requirements outlined in Revenue Procedure 96-32, 1996-1 C.B. 717, which provides guidelines for providing low-income housing that will be treated as charitable, including for each project that (a) at least 75 percent of the units are occupied by residents that qualify as low-income and (b) either at least 20 percent of the units are occupied by residents that also meet the very low-income limit for the area or 40 percent of the units are occupied by residents that also do not exceed 120 percent of the area's very low-income limit, and less than 25 percent of the units are provided at market rates to persons who have incomes in excess of the low-income limit?

Yes

Is your housing affordable to low-income residents?

Yes

If "Yes," describe how your housing is made affordable to low-income residents.

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

Yes

If "Yes," describe these restrictions.

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

Yes

If "Yes," describe what Yes No these charges cover and how they are determined.

Do you provide social services to residents?

Yes

If "Yes," describe these services.

Do you participate in any government housing programs?

Yes

If "Yes," describe these programs.

Schedule G. Successors to Other Organizations

List the name, last address, and EIN of your predecessor organization and describe its activities.

List the owners, partners, principal stockholders, officers, and governing board members of your predecessor organization. Include their names, addresses, and share/interest in the predecessor organization (if for-profit)

Are you a successor to a for-profit organization?

Yes

If "Yes," explain your relationship with the predecessor organization that resulted in your creation and explain why you took over the activities or assets of a for-profit organization or converted from for-profit to nonprofit status;

Explain your relationship with the other organization that resulted in your creation and why you took over the activities or assets of another organization

Do or will you maintain a working relationship with any of the persons listed in question 2 or with any for-profit organization Yes No in which these persons own more than a 35% interest?

Yes

If "Yes," describe the relationship.

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

Yes

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 and describe any restrictions that were placed on the use or sale of the assets.

Were any debts or liabilities transferred from the predecessor for-profit organization to you?

Yes

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.

Will you lease or rent any property or equipment to or from the predecessor organization or any persons listed in Line 2 or a Yes No for-profit organization in which these persons own more than a 35% interest?

Yes

If "Yes," describe the arrangement(s) including how the lease or rental value was determined.

Form 1023 (Rev. 01-2020) Form 1023 (Rev. 01-2020) Name: EIN: 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 1

Public charities and private foundations complete lines 1 through 8 of this section.

Describe the types of educational grants you provide to individuals, such as scholarships, fellowships, loans, etc., including the purpose, number and amount(s) of grants, how the program is publicized, and if you award educational loans, the terms of the loans

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?

Yes

If "No," explain.

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.).

Describe the specific criteria you use to select recipients (for example, specific selection criteria could consist of prior academic performance, financial need, etc.)

Describe any requirement or condition 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. Explain 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.

How do you determine who is on the selection committee for the awards made under your program?

Are relatives of members of the selection committee, or of your officers, directors, or substantial contributors eligible for awards made under your program?

Yes

If "Yes," what measures do you take to ensure unbiased selections?

Do not complete the rest of Schedule H. If you are a private foundation, you will be directed to complete Section II of Schedule H later in the application.

Section 2

Private foundations complete lines 1 through 7 of this section. Public charities do not complete this section.

As a private foundation, do you want this application to be considered as a request for advance approval of grant making procedures?

Yes

If "No," do not complete the rest of Schedule H.

Check the box(es) indicating under which section(s) you want your grant making procedures 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

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

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

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?

Yes

If "No," do not complete the rest of Schedule H

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?

Yes

Do you or will you provide scholarships, fellowships, or educational loans to attend an educational institution to employees of a particular employer?

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

Do you provide scholarships, fellowships, or educational loans to attend an educational institution to children of employees of a particular employer?

Yes

If "Yes," do not complete the rest of Schedule H.

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?

Yes

If "No," do not complete the rest of Schedule H.

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

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; do not complete the rest of Schedule H.

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?

Yes

If "Yes," describe the facts and circumstances 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 or the 10% test