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IRS 1023 Application for Recognition of Exemption Form

IRS 1023 Application for Recognition of Exemption.pdf IRS form 1023. Download this form in Adobe PDF.Download

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(Rev. October  2012)
Reminder: Do Not Include Social Security
Numbers on Publicly Disclosed Forms
Because the IRS is required to disclose approved exemption 
applications and information returns, exempt organiztions shouldn’t
include social security or bank account numbers on these forms. By 
law, with limited exceptions, the IRS has no authority to remove that 
information before making the forms publicly available. Documents
subject to disclosure include supporting documents fled with the 
form, and correspondence with the IRS about the fling.	
Cat. No. 52336F	
Notice  1382	
(Continued)	
 Notice 	1382	 (Rev. 10-2012)	
Department  of the  Treasury 
Internal  Revenue  Service	
Changes for Form 1023
• Mailing address
• Parts IX, X and XI
Changes for Form 1023, Application for
Recognition of Exemption Under Section
501(c)(3) of the Internal Revenue Code
Change of Mailing Address
The mailing address shown on Form 1023 Checklist, page 28, the
frst address under the last checkbox; and in the Instructions for 
Form 1023, page 4 under Where to File, has been changed to:
Internal Revenue Service
P.O. Box 12192
Covington, KY 41012-0192
Changes for Parts IX and X
Changes to Parts IX and X are necessary to comply with new 
regulations that eliminated the advance ruling process. Until 
Form 1023 is revised to refect this change, please follow the 
directions on this notice when completing Part IX and Part X of
Form 1023. For more information about the elimination of the 
advance ruling process, visit us at IRS.gov. In the top right 
“Search” box, type "Elimination of the Advance Ruling Process" 
(exactly as written) and select “Search.”
Part IX. Financial Data
The instructions at the top of Part IX on page 9 of Form 1023 are   
now as follows. 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 fnances for a total of:
a. Three years of fnancial information if you have not completed 
     one tax year, or
b. Four years of fnancial information if you have completed one 
    tax year.
IRS.gov
To fle using a private delivery service, mail to:
201 West Rivercenter Blvd.
Attn: Extracting Stop 312
Covington, KY 41011

Notice	 1382	 (Rev. 10-2012)	
Part X. Public Charity Status
Do not complete line 6a on page 11 of Form 1023, and do not sign 
the form under the heading “Consent Fixing Period of Limitations 
Upon Assessment of Tax Under Section 4940 of the Internal 
Revenue Code.”
Only complete line 6b and line 7 on page 11 of Form 1023, if in 
existence 5 or more tax years.
Part XI. Increase in User Fees
User fee increases are effective for all applications post marked after
January 3, 2010.
1.  $400 for organizations whose gross receipts do not exceed 
$10,000 or less annually over a 4-year period.
2.  $850 for organizations whose gross receipts exceed $10,000 
annually over a 4-year period.
For the current user fee amounts, go to IRS.gov and in the 
“Search” box type “Where Is My Exemption Application,” click on the 
link for that page, and in the second paragraph click on “user fee.”\
 
Alternatively, you can do a search for “user fees” with the applicable 
year in the “Search” box in the top right. Finally, you can also 
call 1-877-829-5500.
Application for reinstatement and retroactive reinstatement. After
your organization’s tax-exempt status was automatically revoked for
failing to fle a return or notice for three consecutive years, your
organization must apply to have its tax-exempt status reinstated. 
You must fle a Form 1023 if applying under section 501(c)(3) or 
Form 1024 if applying under a different Code section, pay the
appropriate user fee, and write “Automatically Revoked” at the top
of your application and the mailing envelope. If approved, the date
of reinstatement will be the date of the application. See Notice
2011-44, 2011-25 I.R.B. 883, at 
http://www.irs.gov/irb/2011-25_IRB/ar10.html, for details.
Transitional relief scheduled to end December 31, 2012. Smaller 
organizations — defned as having annual gross receipts of
$50,000 or less, in its most recently completed tax 
year — that have lost their tax-exempt status because of failure to 
file a required electronic notice (Form 990-N e-Postcard) may be
eligible for transitional relief, including retroactive reinstatement 
and a reduced user fee of $100. See Notice 2011-43, 
2011-25 I.R.B. 882, at
http://www.irs.gov/irb/2011-25_IRB/ar09.html, for details.
Changes for the Instructions for Form 1023 
•Change to Part III. Required Provisions in Your Organizing 
Documents
•Clarification to Appendix A. Sample Conflict of Interest Policy
(Continued)
IRS.gov
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.

Notice	 1382	 (Rev. 10-2012)
Appendix A, Sample Conflict of Interest Policy, is only intended to 
provide an example of a confict of interest policy for organizations.
The sample confict of interest policy does not prescribe any
specifc requirements. Therefore, organizations should use a 
confict of interest policy that best fts their organization.	
Appendix A.  Sample Conict of Interest
Policy
IRS.gov
Changes to Instructions for Form 1023,
Application for Recognition of Exemption 
Under Section 501(c)(3) of the Internal 
Revenue Code (Rev. June 2006)
Part III.  Required Provisions in Your 
Organizing Document
Changes are necessary to comply with Rev. Proc. 82-2, 1982-1 
C.B. 367, to incorporate the state of New York as jurisdiction that
complies with the cy pres doctrine to keep a charitable testamentary
trust from failing the requirement for a dissolution clause under 
Regulation sections 1.501(c)(3)-1(b)(4), when the language of th\
e trust
instrument demonstrates a general intent to beneft charity. Therefore,
the instructions on page 8, line 2c, after the third paragraph now
includes the state of New York in the state listing as an authorized
state. Since the state of New York allows testamentary charitable
trusts formed in that state and the language in the trust
instruments provides for a general intent to beneft charity, you do
not need a specifc provision in your trust agreement or declaration
of trust providing for the distribution of assets upon dissolution.

1	
I.R.S. SPECIFICATIONSTO BE REMOVED BEFORE PRINTING
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transmitted all R
text files for this
cycle update?	Date	
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INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 1 OF 28
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Application for Recognition of Exemption	
Under Section 501(c)(3) of the Internal Revenue Code	
OMB No. 1545-0056	Form	1023	Note: 
If exempt status is
approved, this
application will be open
for public inspection.
(Rev. June 2006)	
Department of the Treasury
Internal Revenue Service	
Identification of Applicant	
c/o Name (if applicable)
2	Full name of organization (exactly as it appears in your  organizing document)	1
For Paperwork Reduction Act Notice, see page 24 of the instructions.
Part I	
Cat. No. 17133K Form	1023	(Rev. 6-2006)	
Use the instructions to complete this application and for a definition o\
f all  bold items.  For additional help, call IRS Exempt
Organizations Customer Account Services toll-free at 1-877-829-5500. Vis\
it our website at  www.irs.gov for forms and
publications. If the required information and documents are not submitte\
d with payment of the appropriate user fee, the
application may be returned to you.	
Employer Identification Number (EIN)4
Mailing address  (Number and street) (see instructions)
3
Month the annual accounting period ends (01 – 12)5
City or town, state or country, and ZIP + 4 Room/Suite	
Primary contact (officer, director, trustee, or 
authorized representative)
6
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 addres\
s 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 repr\
esentative.
7
Was a person who is not one of your officers, directors, trustees, emplo\
yees, 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 financia\
l or tax matters? If “Yes,”
provide the person’s name, the name and address of the person’s fi\
rm, the amounts paid or
promised to be paid, and describe that person’s role.
8
Organization’s website:
9a a 
Name: b Phone:
c  Fax: (optional)
Yes No	
Yes No	
Certain organizations are not required to file an information return (F\
orm 990 or Form 990-EZ). If you
are granted tax-exemption, are you claiming to be excused from filing Fo\
rm 990 or Form 990-EZ? If
“Yes,” explain. See the instructions for a description of organiza\
tions not required to file Form 990 or
Form 990-EZ. Yes No
Date incorporated if a corporation, or formed, if other than a corporati\
on. (MM/DD/YYYY)
11
Were you formed under the laws of a  foreign country?
If “Yes,” state the country.
12
Yes No	//
10
Organization’s email: (optional)
b	
Attach additional sheets to this application if you need more space to a\
nswer fully. Put your name and EIN on each sheet and
identify each answer by Part and line number. Complete Parts I - XI of F\
orm 1023 and submit only those Schedules (A through
H) that apply to you.

1	
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INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 2 OF 28
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Organizational Structure	
1
Part III	
Form	1023	(Rev. 6-2006)	
2
5Are you a 
corporation ? If “Yes,” attach a copy of your articles of incorporation showin\
g certification
of filing  with the appropriate state agency. Include copies of any amendments to y\
our articles and
be sure they also show state filing certification. Yes No	
–	Page	2	Form 1023 (Rev. 6-2006)
Name: EIN:
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 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 th\
ey show state filing certification.
Refer to the instructions for circumstances when an LLC should not file \
its own exemption application.
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 inc\
ludes at least two signatures.
Include signed and dated copies of any amendments.
Are you a  trust? If “Yes,” attach a signed and dated copy of your trust agreement\
. Include signed
and dated copies of any amendments.
Have you been funded? If “No,” explain how you are formed without \
anything of value placed in trust.
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.
3
4a
b	
Yes No
Yes No
Yes No
Yes No
Yes No	
Required Provisions in Your Organizing Document	
1
Part IV
2a 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 con\
firm that your organizing document
meets this requirement. Describe specifically where your organizing docu\
ment meets this requirement, such as
a reference to a particular article or section in your organizing docume\
nt. Refer to the instructions for exempt
purpose language. Location of Purpose Clause (Page, Article, and Paragr\
aph):
The following questions are designed to ensure that when you file this a\
pplication, your organizing document contains the requi
red 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 docu\
ment . Submit your
original and amended organizing documents (showing state filing certifi\
cation if you are a corporation or an LLC) with your app lication.	
Section 501(c)(3) requires that upon dissolution of your organizatio\
n, 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.	
Compensation and Other Financial Arrangements With Your Officers, Direct\
ors, Trustees,
Employees, and Independent Contractors	Part V	
List the names, titles, and mailing addresses of all of your officers, d\
irectors, and trustees. For each person listed, state their
total annual  compensation, or proposed compensation, for all services to the organization, whethe\
r 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 ne eded,
attach a separate sheet. Refer to the instructions for information on wh\
at to include as compensation.	
Name TitleMailing addressCompensation amount
(annual actual or estimated)
1a
Part II
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 c\
opies 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, you r narrative
description of activities should be thorough and accurate. Refer to the \
instructions for information that must be included in your description.	
Narrative Description of Your Activities	
If you checked the box on line 2a, specify the location of your dissolut\
ion clause (Page, Article, and Paragraph).
Do not complete line 2c if you checked box 2a.
2b
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 in\
dicate the state:
2c

1	
I.R.S. SPECIFICATIONSTO BE REMOVED BEFORE PRINTING
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INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 3 OF 28
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
2a	
Form	1023	(Rev. 6-2006)	
Yes No	
–	Page	3	Form 1023 (Rev. 6-2006) Name: EIN:	
Compensation and Other Financial Arrangements With Your Officers, Direct\
ors, Trustees,
Employees, and Independent Contractors (Continued)	Part V	
List the names, titles, and mailing addresses of each of your five highe\
st compensated employees who receive or will
receive compensation of more than $50,000 per year. Use the actual figur\
e, 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 TitleMailing addressCompensation amount
(annual actual or estimated)	
b	
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 TitleMailing addressCompensation amount
(annual actual or estimated)	
c	
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 compensa\
ted independent contractors listed in lines 1a, 1b, and 1c.	
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 trus\
tees.
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 thr\
ough family or business
relationships? If “Yes,” identify the individuals and explain the \
relationship.
For each of your officers, directors, trustees, highest compensated empl\
oyees, and highest
compensated independent contractors listed on lines 1a, 1b, or 1c, attac\
h a list showing their name,
qualifications, average hours worked, and duties.
Do any of your officers, directors, trustees, highest compensated employ\
ees, and highest
compensated independent contractors listed on lines 1a, 1b, or 1c receiv\
e 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 bet\
ween you and the other
organization, and describe the compensation arrangement.
In establishing the compensation for your officers, directors, trustees,\
 highest compensated
employees, and highest compensated independent contractors listed on lin\
es 1a, 1b, and 1c, the
following practices are recommended, although they are not required to o\
btain exemption. Answer
“Yes” to all the practices you use.
Do you or will the individuals that approve compensation arrangements fo\
llow a conflict of interest policy?
Do you or will you approve compensation arrangements in advance of payin\
g compensation?
Do you or will you document in writing the date and terms of approved co\
mpensation arrangements?	
3a
4 Yes No	
Yes No
Yes No
Yes No
Yes No
Yes No	
b
b
b c
c aAre 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.\

1	
I.R.S. SPECIFICATIONSTO BE REMOVED BEFORE PRINTING
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 4 OF 28
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
Yes No	
–	Page	4	Form 1023 (Rev. 6-2006) Name: EIN:	
Compensation and Other Financial Arrangements With Your Officers, Direct\
ors, Trustees,
Employees, and Independent Contractors (Continued)	Part V	
Yes No
Yes No
Yes No
Yes No	
Do you or will you approve compensation arrangements based on informatio\
n about compensation paid by
similarly situated taxable or tax-exempt organizations for similar services, current compen\
sation surveys
compiled by independent firms, or actual written offers from similarly s\
ituated organizations? Refer to the
instructions for Part V, lines 1a, 1b, and 1c, for information on what t\
o include as compensation.
Do you or will you record in writing both the information on which you r\
elied to base your decision
and its source?
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, a\
nd 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.
What procedures will you follow to assure that persons who have a confli\
ct 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 confli\
ct 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 t\
o 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 comp\
ensation.	
e
f
g
5a
b
c
6a	
Do you or will you compensate any of your employees, other than your off\
icers, directors, trustees,
or your five highest compensated employees who receive or will receive c\
ompensation of more than
$50,000 per year, through non-fixed payments, such as discretionary bonu\
ses or revenue-based
payments? If “Yes,” describe all non-fixed compensation arrangemen\
ts, including how the amounts
are or will be determined, who is or will be eligible for such arrangeme\
nts, 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 instruction\
s for Part V, lines 1a, 1b,
and 1c, for information on what to include as compensation.
Do you or will you purchase any goods, services, or assets from any of y\
our officers, directors,
trustees, highest compensated employees, or highest compensated independ\
ent 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 t\
han  fair market
value . Attach copies of any written contracts or other agreements relating to\
 such purchases.
Do you or will you sell any goods, services, or assets to any of your of\
ficers, directors, trustees,
highest compensated employees, or highest compensated independent contra\
ctors listed in lines 1a,
1b, or 1c? If “Yes,” describe any such sales that you made or inte\
nd 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
Yes No	
b
b
7a	
Do you or will you record in writing the decision made by each individua\
l who decided or voted on
compensation arrangements?
Yes No	d	
Do you or will you have any leases, contracts, loans, or other agreement\
s with your officers, directors,
trustees, highest compensated employees, or highest compensated independ\
ent contractors listed in
lines 1a, 1b, or 1c? If “Yes,” provide the information requested i\
n lines 8b through 8f.
Describe any written or oral arrangements that you made or intend to mak\
e.
Identify with whom you have or will have such arrangements.
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.
Attach copies of any signed leases, contracts, loans, or other agreement\
s relating to such arrangements.	
Yes No	
b
8a
c
de f	
Yes No	9a Do you or will you have any leases, contracts, loans, or other agreement\
s with any organization in
which any of your officers, directors, or trustees are also officers, di\
rectors, or trustees, or in which
any individual officer, director, or trustee owns more than a 35% intere\
st? If “Yes,” provide the
information requested in lines 9b through 9f.

1	
I.R.S. SPECIFICATIONSTO BE REMOVED BEFORE PRINTING
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 5 OF 28
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	5	Form 1023 (Rev. 6-2006) Name: EIN:	
Compensation and Other Financial Arrangements With Your Officers, Direct\
ors, Trustees,
Employees, and Independent Contractors (Continued)	Part V
b
c
d
e
f Describe any written or oral arrangements 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.
Explain how you determine or will determine you pay no more than fair ma\
rket value or that you are
paid at least fair market value.	
Attach a copy of any signed leases, contracts, loans, or other agreement\
s relating to such arrangements.	
Your Members and Other Individuals and Organizations That Receive Benefi\
ts From You	Part VI	
Yes No	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 fun\
ds to individuals.
1a	
The following “Yes” or “No” questions relate to goods, servi\
ces, 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.)
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 fun\
ds to organizations.
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.
Do any individuals who receive goods, services, or funds through your pr\
ograms have a family or
business relationship with any officer, director, trustee, or with any o\
f 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 good\
s, services, or funds. Yes No	
Yes No
Yes No	
b
2
3	
Your History	Part VII	
Yes No	Are you a  successor  to another organization? Answer “Yes,” if you have taken or will t\
ake over the
activities of another organization; you took over 25% or more of the fai\
r market value of the net
assets of another organization; or you were established upon the convers\
ion of an organization from
for-profit to non-profit status. If “Yes,” complete Schedule G.
1	
The following “Yes” or “No” questions relate to your history\
. (See instructions.)
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
2	
Your Specific Activities	Part VIII	
Yes No	Do you support or oppose candidates in 
political campaigns in any way? If “Yes,” explain.
1	
The following “Yes” or “No” questions relate to specific act\
ivities that you may conduct. Check the appropriate box. Your
answers should pertain to  past, present, and planned  activities. (See instructions.)
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
2a	
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 F\
orm 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 activit\
ies. Include the time and money
spent on your attempts to influence legislation as compared to your tota\
l activities.
b
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 o\
r expected to be paid in
operating these activities.  Revenue and expenses should be provided for the time periods specified
in Part IX, Financial Data.
Do you or will you enter into contracts or other agreements with individ\
uals 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 arrange\
ments, 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 mar\
ket value. Attach copies or
any written contracts or other agreements relating to such arrangements.\
List the states and local jurisdictions, including Indian Reservations, \
in which you conduct or will
conduct gaming or bingo.
3a
b
c Yes No	
Yes No

1	
I.R.S. SPECIFICATIONSTO BE REMOVED BEFORE PRINTING
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PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	6	Form 1023 (Rev. 6-2006) Name: EIN:
4aDo you or will you undertake  fundraising? If “Yes,” check all the fundraising programs you do or will
conduct. (See instructions.)
mail solicitations
email solicitations
personal solicitations
vehicle, boat, plane, or similar donations
foundation grant solicitations phone solicitations
accept donations on your website
receive donations from another organization’s website
government grant solicitations
Other	Yes No	
Attach a description of each fundraising program.
b
5 Do you or will you have written or oral contracts with any individuals o\
r 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 contrac\
ts or agreements.
Yes No
Do you or will you engage in fundraising activities for other organizati\
ons? If “Yes,” describe these
arrangements. Include a description of the organizations for which you r\
aise funds and attach copies
of all contracts or agreements.
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 organiza\
tion, 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 donor\
s.
Are you  affiliated  with a governmental unit? If “Yes,” explain.
Do you or will you engage in  economic development? If “Yes,” describe your program.
Describe in full who benefits from your economic development activities \
and how the activities
promote exempt purposes.
6a
b c
d
e	Yes No
Yes No
Yes No
Yes No	
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 rel\
ationship(s) between the
developer and your officers, directors, or trustees.
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 manage\
r, and any business or family
relationship(s) between the manager and your officers, directors, or t\
rustees.
If there is a business or family relationship between any manager or dev\
eloper and your officers,
directors, or trustees, identify the individuals, explain the relationsh\
ip, describe how contracts are
negotiated at arm’s length so that you pay no more than fair market v\
alue, 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 part\
ners other than section
501(c)(3) organizations? If “Yes,” describe the activities of \
these joint ventures in which you
participate.
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.
Do you provide child care so that parents or caretakers of children you \
care for can be  gainfully
employed  (see instructions)? If “No,” explain how you qualify as a childc\
are organization described
in section 501(k).
Of the children for whom you provide child care, are 85% or more of them\
 cared for by you to
enable their parents or caretakers to be gainfully employed (see instru\
ctions)? If “No,” explain how
you qualify as a childcare organization described in section 501(k).
Are your services available to the general public? If “No,” descri\
be the specific group of people for
whom your activities are available. Also, see the instructions and expla\
in how you qualify as a
childcare organization described in section 501(k).
Do you or will you publish, own, or have rights in music, literature, ta\
pes, 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
Yes No
Yes No
Yes No
Yes No
Yes No	
7a
8
9a
10 b b
c
c
d
Yes No	
Yes No	
Your Specific Activities (Continued)	Part VIII

1	
I.R.S. SPECIFICATIONSTO BE REMOVED BEFORE PRINTING
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FORM 1023, PAGE 7 OF 28
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PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	7	Form 1023 (Rev. 6-2006) Name: EIN:	
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.
Name the foreign countries and regions within the countries in which you\
 operate.
Describe your operations in each country and region in which you operate\
.
Describe how your operations in each country and region further your exe\
mpt purposes.	Yes No	12a
b
c
d
13a
bc
d
e Do you or will you make grants, loans, or other distributions to organiz\
ation(s)? If “Yes,” answer lines
13b through 13g. If “No,” go to line 14a.	
Describe how your grants, loans, or other distributions to organizations\
 further your exempt purposes.
Do you have written contracts with each of these organizations? If “Y\
es,” attach a copy of each contract.
Identify each recipient organization and any 
relationship between you and the recipient organization.
Describe the records you keep with respect to the grants, loans, or othe\
r distributions you make. Yes No	
Yes No	
Do you or will you accept contributions of: real property; conservation \
easements; closely held
securities; intellectual property such as patents, trademarks, and copyr\
ights; works of music or art;
licenses; royalties; automobiles, boats, planes, or other vehicles; or c\
ollectibles 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	11
f Describe your selection process, including whether you do any of the fol\
lowing:
Yes No	
Do you require an application form? If “Yes,” attach a copy of the\
 form.
Do you require a grant proposal? If “Yes,” describe whether the gr\
ant 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 rep\
orts 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 i\
n case such funds are,
or appear to be, misused.
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.
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.
Provide the name of each foreign organization, the country and regions w\
ithin a country in which
each foreign organization operates, and describe any relationship you ha\
ve with each foreign
organization.
Does any foreign organization listed in line 14b accept contributions ea\
rmarked for a specific country
or specific organization? If “Yes,” list all earmarked organizatio\
ns or countries.
Do your contributors know that you have ultimate authority to use contri\
butions made to you at your
discretion for purposes consistent with your exempt purposes? If “Yes\
,” describe how you relay this
information to contributors.
Do you or will you make pre-grant inquiries about the recipient organiza\
tion? If “Yes,” describe these
inquiries, including whether you inquire about the recipient’s financ\
ial status, its tax-exempt status
under the Internal Revenue Code, its ability to accomplish the purpose f\
or which the resources are
provided, and other relevant information.
Do you or will you use any additional procedures to ensure that your dis\
tributions to foreign
organizations are used in furtherance of your exempt purposes? If “Ye\
s,” describe these procedures,
including site visits by your employees or compliance checks by impartia\
l experts, to verify that grant
funds are being used appropriately. (ii) (i)
g
14a b
c
d
e
f Yes No	
Yes No
Yes No
Yes No
Yes No
Yes No	
Your Specific Activities 
(Continued)	Part VIII

1	
I.R.S. SPECIFICATIONSTO BE REMOVED BEFORE PRINTING
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INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 8 OF 28
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PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	8	Form 1023 (Rev. 6-2006) Name: EIN:	
Do you or will you provide scholarships, fellowships, educational loans,\
 or other educational grants to
individuals, including grants for travel, study, or other similar purpos\
es? If “Yes,” complete
Schedule H.
Note: Private foundations may use Schedule H to request advance approval of individual grant
procedures.
22
Yes No
Do you have a close connection  with any organizations? If “Yes,” explain.
Are you applying for exemption as a  cooperative hospital service organization  under section
501(e)? If “Yes,” explain.
Are you applying for exemption as a  cooperative service organization of operating educational
organizations  under section 501(f)? If “Yes,” explain.
Are you applying for exemption as a  charitable risk pool under section 501(n)? If “Yes,” explain.
Is your main function to provide  hospital or medical care ? If “Yes,” complete Schedule C.
Do you or will you provide  low-income housing or housing for the elderly or handicapped ? If
“Yes,” complete Schedule F.
15
16
17
18
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.	
19
20
21 Yes No	
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No	
Your Specific Activities 
(Continued)	Part VIII

1	
I.R.S. SPECIFICATIONSTO BE REMOVED BEFORE PRINTING
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INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 9 OF 28
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	9	Form 1023 (Rev. 6-2006) Name: EIN:	
Financial Data	
24
For purposes of this schedule, years in existence refer to completed tax\
 years. If in existence 4 or more years, complete the
schedule for the most recent 4 tax years. If in existence more than 1 ye\
ar but less than 4 years, complete the statements for
each year in existence and provide projections of your likely revenues a\
nd expenses based on a reasonable and good faith
estimate of your future finances for a total of 3 years of financial inf\
ormation. If in existence less than 1 year, provide pro
jections
of your likely revenues and expenses for the current year and the 2 foll\
owing years, based on a reasonable and good faith
estimate of your future finances for a total of 3 years of financial inf\
ormation. (See instructions.)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23 A. Statement of Revenues and Expenses	
Type of revenue or expense
Current tax year3 prior tax years or 2 succeeding tax years
(a) From
To (e) 
Provide Total for
(a) through (d)	
(b) From
To (c)
From
To (d)
From
To	
Revenues
Expenses	
Gifts, grants, and
contributions received (do not
include unusual grants)
Membership fees received
Gross investment income
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
schedule and see instructions)
Unusual grants
Total Revenue
Add lines 10 through 12
Fundraising expenses
Contributions, gifts, grants,
and similar amounts paid out
(attach an itemized list)
Disbursements to or for the
benefit of members (attach an
itemized list)
Compensation of officers,
directors, and trustees
Other salaries and wages
Interest expense
Occupancy (rent, utilities, etc.)
Depreciation and depletion
Professional fees
Any expense not otherwise
classified, such as program
services (attach itemized list)
Total Expenses
Add lines 14 through 23	
Part IX

1	
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PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	10	Form 1023 (Rev. 6-2006) Name: EIN:	
Financial Data (Continued)	
B. Balance Sheet (for your most recently completed tax year)	Year End:	
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
1ab Assets
(Whole dollars)
Cash	
Accounts receivable, net
Inventories
Bonds and notes receivable (attach an itemized list)
Corporate stocks (attach an itemized list)
Loans receivable (attach an itemized list)
Other investments (attach an itemized list)
Depreciable and depletable assets (attach an itemized list)
Land
Other assets (attach an itemized list)	
Total Assets (add lines 1 through 10)	
Liabilities
Accounts payable	
Contributions, gifts, grants, etc. payable
Mortgages and notes payable (attach an itemized list)
Other liabilities (attach an itemized list)	
Total Liabilities (add lines 12 through 15)	
Fund Balances or Net Assets
Total fund balances or net assets	
Total Liabilities and Fund Balances or Net Assets (add lines 16 and 17)\
	
Have there been any substantial changes in your assets or liabilities si\
nce the end of the period
shown above? If “Yes,” explain.	
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18	
Yes No	
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 ar\
e a private foundation, Part X is designed to further
determine whether you are a  private operating foundation. (See instructions.)	
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.
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 5\
01(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 sp\
ecifically where your
organizing document meets this requirement, such as a reference to a par\
ticular article or section in
your organizing document or by operation of state law. See the instructi\
ons, including Appendix B,
for information about the special provisions that need to be contained i\
n your organizing document.
Go to line 2.
Are you a private operating foundation? To be a private operating founda\
tion you must engage
directly in the active conduct of charitable, religious, educational, an\
d similar activities, as opposed
to indirectly carrying out these activities by providing grants to indiv\
iduals or other organizations. If
“Yes,” go to line 3. If “No,” go to the signature section of\
 Part XI.
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.
Have you attached either (1) an affidavit or opinion of counsel, (inc\
luding a written affidavit or opinion
from a certified public accountant or accounting firm with expertise reg\
arding this tax law matter),
that sets forth facts concerning your operations and support to demonstr\
ate that you are likely to
satisfy the requirements to be classified as a private operating foundat\
ion; or (2) a statement
describing your proposed operations as a private operating foundation?
2
3
4	
Yes No
Yes No
Yes No
Yes No	
Part X
Part IX
5
a
c
d
b	If you answered “No” to line 1a, indicate the type of public chari\
ty status you are requesting by checking one of the choices b
elow.
You may check only one box.
The organization is not a private foundation because it is:
509(a)(1) and 170(b)(1)(A)(i)—a church or a convention or\
 association of churches. Complete and attach Schedule A.
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 attac\
h Schedule C.
509(a)(3)—an organization supporting either one or more organizat\
ions described in line 5a through c, f, g, or h
or a publicly supported section 501(c)(4), (5), or (6) organizat\
ion. Complete and attach Schedule D.

1	
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PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	11	Form 1023 (Rev. 6-2006) Name: EIN:	
Public Charity Status (Continued)	
Yes No	
e
f
g
h
i
6
(i)
(ii)
7 509(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 f\
or the benefit of a college or university that is owned or
operated by a governmental unit.
509(a)(1) and 170(b)(1)(A)(vi)—an organization that recei\
ves a substantial part of its financial support in the form
of contributions from publicly supported organizations, from a governmen\
tal unit, or from the general public.
509(a)(2)—an organization that normally receives not more than on\
e-third of its financial support from gross
investment income 
and receives more than one-third of its financial support from contribut\
ions, 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 5g o\
r 5h. The organization would like the IRS to
decide the correct status.	
If you checked box g, h, or i in question 5 above, you must request eith\
er an  advance or a definitive ruling  by
selecting one of the boxes below. Refer to the instructions to determine\
 which type of ruling you are eligible to receive.
Request for Advance Ruling:  By checking this box and signing the consent, pursuant to section 6501(\
c)(4) of
the Code you request an advance ruling and agree to extend the statute o\
f limitations on the assessment of
excise tax under section 4940 of the Code. The tax will apply only if yo\
u do not establish public support status
at the end of the 5-year advance ruling period. The assessment period wi\
ll be extended for the 5 advance ruling
years to 8 years, 4 months, and 15 days beyond the end of the first year\
. You have the right to refuse or limit
the extension to a mutually agreed-upon period of time or issue(s). Pu\
blication 1035,  Extending the Tax
Assessment Period,  provides a more detailed explanation of your rights and the consequences\
 of the choices
you make. You may obtain Publication 1035 free of charge from the IRS we\
b site at  www.irs.gov or by calling
toll-free 1-800-829-3676. Signing this consent will not deprive you of a\
ny appeal rights to which you would
otherwise be entitled. If you decide not to extend the statute of limita\
tions, you are not eligible for an advance
ruling.
a	
b Request for Definitive Ruling: 
Check this box if you have completed one tax year of at least 8 full mon\
ths and
you are requesting a definitive ruling. To confirm your public support s\
tatus, answer line 6b(i) if you checked box
g in line 5 above. Answer line 6b(ii) if you checked box h in line 5 a\
bove. If you checked box i in line 5 above,
answer both lines 6b(i) and (ii).
(a)
(b)Enter 2% of line 8, column (e) on Part IX-A. Statement of Revenues and\
 Expenses.
Attach a list showing the name and amount contributed by each person, co\
mpany, or organization whose
gifts totaled more than the 2% amount. If the answer is “None,” ch\
eck this box.
For each year amounts are included on lines 1, 2, and 9 of Part IX-A. St\
atement of Revenues and
Expenses, attach a list showing the name of and amount received from eac\
h 
disqualified person. If the
answer is “None,” check this box.
For each year amounts are 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 th\
an a disqualified person, whose
payments were more than the larger of (1) 1% of line 10, Part IX-A. St\
atement of Revenues and
Expenses, or (2) $5,000. If the answer is “None,” check this box\
.
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 i\
t is unusual. (a)
(b)	
(Date)
(Signature of Officer, Director, Trustee, or other
authorized official)	
(Type or print title or authority of signer)	
Part X	
Consent Fixing Period of Limitations Upon Assessment of Tax Under Sectio\
n 4940 of the Internal Revenue Code
For Organization
For IRS Use Only	
(Date)	
(Type or print name of signer)	
IRS Director, Exempt Organizations

1	
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PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	12	Form 1023 (Rev. 6-2006) Name: EIN:
I declare under the penalties of perjury that I am authorized to sign th\
is application on behalf of the above organization and that I have examined this
application, including the accompanying schedules and attachments, and t\
o the best of my knowledge it is true, correct, and com plete.
Please
Sign
Here	
(Date)
(Signature of Officer, Director, Trustee, or other
authorized official)		
(Type or print title or authority of signer)	
User Fee Information	Part XI	
Have your annual gross receipts averaged or are they expected to average\
 not more than $10,000?	1
You must include a user fee payment with this application. It will not b\
e processed without your paid user fee. 
If your average
annual gross receipts have exceeded or will exceed $10,000 annually over\
 a 4-year period, you must submit payment of $750. If
your gross receipts have not exceeded or will not exceed $10,000 annuall\
y over a 4-year period, the required user fee payment
is $300. See instructions for Part XI, for a definition of  gross receipts over a 4-year period. 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 ty\
pe “User
Fee” in the keyword box, or call Customer Account Services at 1-877-8\
29-5500 for current information.	
Check the box if you have enclosed the reduced user fee payment of $300 \
(Subject to change).	2	
Check the box if you have enclosed the user fee payment of $750 (Subjec\
t to change).	3 Yes No	
If “Yes,” check the box on line 2 and enclose a user fee payment o\
f $300 (Subject to change—see above).
If “No,” check the box on line 3 and enclose a user fee payment of\
 $750 (Subject to change—see above).	
(Type or print name of signer)	
Reminder: 
Send the completed Form 1023 Checklist with your filled-in-application.

1	
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INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 13 OF 28
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Form	1023	(Rev. 6-2006)	
–	Page	13	Form 1023 (Rev. 6-2006) Name: EIN:	
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No	
Schedule A. Churches	
1a
b
2a
c
3
4a
5a
6
7
8a
d
9
10
11a
12
13
14
15
16
17 Do you have a written creed, statement of faith, or summary of beliefs? \
If “Yes,” attach copies of
relevant documents.
Do you have a form of worship? If “Yes,” describe your form of wor\
ship.
Do you have a formal code of doctrine and discipline? If “Yes,” de\
scribe your code of doctrine and
discipline.
Do you have a distinct religious history? If “Yes,” describe your \
religious history.
Do you have a literature of your own? If “Yes,” describe your lite\
rature.
Describe the organization’s religious hierarchy or ecclesiastical gov\
ernment.
Do you have regularly scheduled religious services? If “Yes,” desc\
ribe the nature of the services and
provide representative copies of relevant literature such as church bull\
etins.
What is the average attendance at your regularly scheduled religious ser\
vices?
Do you have an established place of worship? If “Yes,” refer to th\
e instructions for the information
required.
Do you own the property where you have an established place of worship?
Do you have an established congregation or other regular membership grou\
p? If “No,” refer to the
instructions.
How many members do you have?
Do you have a process by which an individual becomes a member? If “Ye\
s,” describe the process
and complete lines 8b–8d, below.
If you have members, do your members have voting rights, rights to parti\
cipate in religious functions,
or other rights? If “Yes,” describe the rights your members have.
May your members be associated with another denomination or church?
Are all of your members part of the same 
family?
Do you conduct baptisms, weddings, funerals, etc.?
Do you have a school for the religious instruction of the young?
Do you have a minister or religious leader? If “Yes,” describe thi\
s person’s role and explain whether
the minister or religious leader was ordained, commissioned, or licensed\
 after a prescribed course of
study.
Do you have schools for the preparation of your ordained ministers or re\
ligious leaders?
Is your minister or religious leader also one of your officers, director\
s, or trustees?
Do you ordain, commission, or license ministers or religious leaders? If\
 “Yes,” describe the
requirements for ordination, commission, or licensure.
Are you part of a group of churches with similar beliefs and structures?\
 If “Yes,” explain. Include the
name of the group of churches.
Do you issue church charters? If “Yes,” describe the requirements \
for issuing a charter.
Did you pay a fee for a church charter? If “Yes,” attach a copy of\
 the charter.
Do you have other information you believe should be considered regarding\
 your status as a church?
If “Yes,” explain.
b
b
b
b
b
c	
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

1	
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Form	1023	(Rev. 6-2006)	
–	Page	14	Form 1023 (Rev. 6-2006) Name: EIN:	
Yes No
Yes No	
Schedule B. Schools, Colleges, and Universities	
1a
b
2a
3
4
5
6
7
8 Do you normally have a regularly scheduled curriculum, a regular faculty\
 of qualified teachers, a
regularly enrolled student body, and facilities where your educational a\
ctivities are regularly carried
on? If “No,” do not complete the remainder of Schedule B.
b	
If you operate a school as an activity, complete Schedule B	
Section I Operational Information	
Is the primary function of your school the presentation of formal instru\
ction? If “Yes,” describe your
school in terms of whether it is an elementary, secondary, college, tech\
nical, or other type of school.
If “No,” do not complete the remainder of Schedule B.
Are you a public school because you are operated by a state or subdivisi\
on of a state? If “Yes,”
explain how you are operated by a state or subdivision of a state. Do no\
t complete the remainder of
Schedule B.
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 pred\
ominantly from government funds
or property. Submit a copy of your funding agreement regarding governmen\
t funding. Do not
complete the remainder of Schedule B.
In what public school district, county, and state are you located?
Were you formed or substantially expanded at the time of public school d\
esegregation in the above
school district or county?
Has a state or federal administrative agency or judicial body ever deter\
mined that you are racially
discriminatory? If “Yes,” explain.
Has your right to receive financial aid or assistance from a governmenta\
l agency ever been revoked
or suspended? If “Yes,” explain.
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.
Note. Make sure your answer is consistent with the information provided in Par\
t VIII, line 7a.
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 ma\
naged by others, the names of the
persons or organizations that manage or will manage your activities or f\
acilities, 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 servic\
es.
Note.  Answer “Yes” if you manage or intend to manage your programs throu\
gh your own employees
or by using volunteers. Answer “No” if you engage or intend to eng\
age a separate organization or
independent contractor. Make sure your answer is consistent with the inf\
ormation provided in Part
VIII, line 7b. Yes No	
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No	
Section II
Establishment of Racially Nondiscriminatory Policy	
Information required by  Revenue Procedure 75-50.
1
2
3
4 Have you adopted a racially nondiscriminatory policy as to students in y\
our organizing document,
bylaws, or by resolution of your governing body? If “Yes,” state w\
here the policy can be found or
supply a copy of the policy. If “No,” you must adopt a nondiscrimi\
natory policy as to students
before submitting this application. See Publication 557.	
Do your brochures, application forms, advertisements, and catalogues dea\
ling with student
admissions, programs, and scholarships contain a statement of your racia\
lly nondiscriminatory
policy?
If “Yes,” attach a representative sample of each document.
If “No,” by checking the box to the right you agree that all futur\
e printed materials, including website
content, will contain the required nondiscriminatory policy statement.
b a
Have you published a notice of your nondiscriminatory policy in a newspa\
per of general circulation
that serves all racial segments of the community? (See the instructions\
 for specific requirements.) If
“No,” explain.
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,” f\
or any of the above, explain fully.	
Yes No
Yes No
Yes No
Yes No	


1	
I.R.S. SPECIFICATIONSTO BE REMOVED BEFORE PRINTING
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FORM 1023, PAGE 15 OF 28
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PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	15	Form 1023 (Rev. 6-2006) Name: EIN:	
Schedule B. Schools, Colleges, and Universities (Continued)	
5Complete 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.
Yes No	
If you are not operational, submit an estimate based on the best informa\
tion available (such as the racial composition of
the community served).
Racial Category	(a) Student Body(b) Faculty(c) Administrative Staff
Current Year Next Year
Total Current Year
Current Year
Next Year Next Year	
6In the table below, provide the number and amount of loans and scholarsh\
ips awarded to students enrolled by racial
categories.	
Racial Category	Number of Loans Amount of Loans Number of Scholarships	
Current Year	Next Year
Total	Current Year Current Year	Next YearNext Year	
Amount of Scholarships
Current Year	Next Year	
7aAttach 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 mainta\
in segregated public or
private school education? If “Yes,” explain.
Will you maintain records according to the non-discrimination provisions\
 contained in Revenue
Procedure 75-50? If “No,” explain. (See instructions.)
8b
Yes No

1	
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Form	1023	(Rev. 6-2006)	
–	Page	16	Form 1023 (Rev. 6-2006) Name: EIN:	
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,” wh\
ich
includes an organization whose principal purpose or function is providin\
g  hospital or medical care .
Complete Section I below.
Yes No
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 organ\
ization,” 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 hosp\
ital. Complete Section II.
7
8b Yes No
1a
Section I	
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.	
Hospitals	
2a
bc
3a
4a
5a
de
6a
9 Do you or will you provide medical services to all individuals in your c\
ommunity who can pay for
themselves or have private health insurance? If “No,” explain.
Do you or will you provide medical services to all individuals in your c\
ommunity who participate in
Medicare? If “No,” explain.
Do you or will you provide medical services to all individuals in your c\
ommunity who participate in
Medicaid? If “No,” explain.
Do you or will you require persons covered by Medicare or Medicaid to pa\
y a deposit before
receiving services? If “Yes,” explain.
Does the same deposit requirement, if any, apply to all other patients? \
If “No,” explain.
Do you or will you maintain a full-time emergency room? If “No,” e\
xplain why you do not maintain a
full-time emergency room. Also, describe any emergency services that you\
 provide.
Do you have a policy on providing emergency services to persons without \
apparent means to pay? If
“Yes,” provide a copy of the policy.
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 agreem\
ents.
Do you provide for a portion of your services and facilities to be used \
for charity patients? If “Yes,”
answer 5b through 5e.
Explain your policy regarding charity cases, including how you distingui\
sh between charity care and
bad debts. Submit a copy of your written policy.
Provide data on your past experience in admitting charity patients, incl\
uding amounts you expend for
treating charity care patients and types of services you provide to char\
ity care patients.
Describe any arrangements you have with federal, state, or local governm\
ents or government
agencies for paying for the cost of treating charity care patients. Subm\
it 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.
Do you or will you carry on a formal program of medical training or medi\
cal research? If “Yes,”
describe such programs, including the type of programs offered, the scop\
e of such programs, and
affiliations with other hospitals or medical care providers with which y\
ou carry on the medical training
or research programs.
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 prog\
rams, and affiliation with
other hospitals or medical care providers with which you offer community\
 education programs.
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 th\
e means used to determine that
you are paid at least fair market value, and submit representative lease\
 agreements.
Is your board of directors comprised of a majority of individuals who ar\
e representative of the
community you serve? Include a list of each board member’s name and b\
usiness, financial, or
professional relationship with the hospital. Also, identify each board m\
ember who is representative of
the community and describe how that individual is a community representa\
tive.
Do you participate in any joint ventures? If “Yes,” state your own\
ership percentage in each joint
venture, list your investment in each joint venture, describe the tax st\
atus of other participants in
each joint venture (including whether they are section 501(c)(3) or\
ganizations), describe the activities
of each joint venture, describe how you exercise control over the activi\
ties of each joint venture, and
describe how each joint venture furthers your exempt purposes. Also, sub\
mit copies of all
agreements.
Note. 
Make sure your answer is consistent with the information provided in Par\
t VIII, line 8.
b
b
b
c c	
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

1	
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FORM 1023, PAGE 17 OF 28
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PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	17	Form 1023 (Rev. 6-2006) Name: EIN:	
Schedule C. Hospitals and Medical Research Organizations (Continued)	
Section I	Hospitals (Continued)	
10Do 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 ma\
naged by others, the names of the
persons or organizations that manage or will manage your activities or f\
acilities, 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 servic\
es.
Note.  Answer “Yes” if you do manage or intend to manage your programs th\
rough your own
employees or by using volunteers. Answer “No” if you engage or int\
end to engage a separate
organization or independent contractor. Make sure your answer is consist\
ent with the information
provided in Part VIII, line 7b.	Yes No	
Do you or will you offer recruitment incentives to physicians? If “Ye\
s,” describe your recruitment
incentives and attach copies of all written recruitment incentive polici\
es.
Do you or will you lease equipment, assets, or office space from physici\
ans who have a financial or
professional relationship with you? If “Yes,” explain how you esta\
blish a fair market value for the
lease.
Have you purchased medical practices, ambulatory surgery centers, or oth\
er 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 descr\
ibe how you arrived at fair
market value, including copies of appraisals.
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 “Ye\
s,” submit a copy of the policy and
explain how the policy has been adopted, such as by resolution of your g\
overning board. If “No,”
explain how you will avoid any conflicts of interest in your business de\
alings.
11
12
13
14	Yes No
Yes No
Yes No
Yes No	
Section II	Medical Research Organizations	
1
2
3
Name the hospitals with which you have a relationship and describe the r\
elationship. Attach copies
of written agreements with each hospital that demonstrate continuing rel\
ationships between you and
the hospital(s).
Attach a schedule describing your present and proposed activities for th\
e 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 port\
ion of your assets directly
devoted to medical research.

1	
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FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	18	Form 1023 (Rev. 6-2006) Name: EIN:	
Schedule D. Section 509(a)(3) Supporting Organizations	
Section I	Identifying Information About the Supported Organization(s)	
Yes No	
Section II	Relationship with Supported Organization(s)—Three Tests	
1
2
3	State the names, addresses, and EINs of the supported organizations. If \
additional space is needed, attach a separate
sheet.
NameAddressEIN
–
–
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.
Do the supported organizations have tax-exempt status under section 501(\
c)(4), 501(c)(5), or
501(c)(6)?
If “Yes,” for each 501(c)(4), (5), or (6) organization sup\
ported, provide the following financial
information:
If “No,” attach a statement describing how each organization you s\
upport is a public charity under
section 509(a)(1) or (2).	
Yes No	
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 publi\
cly 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 support\
ed organizations.
1
2
3Information to establish the “operated, supervised, or controlled by”\
 relationship (Test 1)
Is a majority of your governing board or officers elected or appointed b\
y the supported
organization(s)? If “Yes,” describe the process by which your go\
verning board is appointed and
elected; go to Section III. If “No,” continue to line 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 p\
rocess by which your governing
board is appointed and elected; go to Section III. If “No,” go to \
line 3.
Information to establish the “operated in connection with” respons\
iveness test (Test 3)	
Are you a trust from which the named supported organization(s) can enf\
orce 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.
Information to establish the alternative “operated in connection with\
” responsiveness test (Test 3)
Do the officers, directors, trustees, or members of the supported organi\
zation(s) elect or appoint one
or more of your officers, directors, or trustees? If “Yes,” explai\
n and provide documentation; go to
line 4d, below. If “No,” go to line 4b.
Do one or more members of the governing body of the supported organizati\
on(s) also serve as your
officers, directors, or trustees or hold other important offices with re\
spect to you? If “Yes,” explain
and provide documentation; go to line 4d, below. If “No,” go to li\
ne 4c.
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.
Do the supported organization(s) have a significant voice in your inve\
stment 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.
Describe and provide copies of written communications documenting how yo\
u made the supported
organization(s) aware of your supporting activities.
4
a
b
c
d
e Yes No	
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No	
●
Part IX-A. Statement of Revenues and Expenses, lines 1–13 and
● Part X, lines 6b(ii)(a), 6b(ii)(b), and 7.

1	
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INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 19 OF 28
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PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	19	Form 1023 (Rev. 6-2006) Name: EIN:	
Schedule D. Section 509(a)(3) Supporting Organizations (Continued)	
Section II	Relationship with Supported Organization(s)—Three Tests  (Continued)	
6
a
b
c
d Yes No	
Yes No
Yes No	
5
Information to establish the “operated in connection with” integra\
l part test (Test 3)
Do you conduct activities that would otherwise be carried out by the sup\
ported organization(s)? If
“Yes,” explain and go to Section III. If “No,” continue to l\
ine 6a.	
Yes No	
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.)
If “No,” state the percentage of your income that you distribute t\
o each supported organization. Also
explain how you ensure that the supported organization(s) are attentiv\
e to your operations.
How much do you contribute annually to each supported organization? Atta\
ch 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.
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,” answe\
r line 7b.
Attach a statement describing whether there has been an historic and con\
tinuing relationship
between you and the supported organization(s).	
7a
b
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 c\
haritable class of
beneficiaries. If your organizing document complies with this requiremen\
t, answer “Yes.” If your
organizing document does not comply with this requirement, answer “No\
,” and see the instructions.
If you met relationship Test 3 in Section II, your organizing document m\
ust generally specify the
supported organization(s) by name. If your organizing document complie\
s with this requirement,
answer “Yes,” and go to Section IV. If your organizing document do\
es not comply with this
requirement, answer “No,” and see the instructions. Yes No	
Yes No	
Section IV	Disqualified Person Test	
1a
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 disqua\
lified persons with respect to you.
Do any persons who are disqualified persons with respect to you, (excep\
t individuals who are
disqualified persons only because they are foundation managers), appoin\
t any of your foundation
managers? If “Yes,” (1) describe the process by which disqualifi\
ed persons appoint any of your
foundation managers, (2) provide the names of these disqualified perso\
ns 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 have a family or business relationship with any disqu\
alified persons with
respect to you, (except individuals who are disqualified persons only b\
ecause 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 per\
sons appoint any of your
foundation managers, (2) provide the names of these disqualified perso\
ns, the individuals with a
family or business relationship with disqualified persons, and the found\
ation managers appointed,
and (3) explain how control is vested over your operations (including\
 assets and activities) in
individuals other than disqualified persons.
Do any persons who are disqualified persons, (except individuals who ar\
e disqualified persons only
because they are foundation managers), have any influence regarding you\
r operations, including your
assets or activities? If “Yes,” (1) provide the names of these d\
isqualified persons, (2) explain how
influence is exerted over your operations (including assets and activit\
ies), and (3) explain how control
is vested over your operations (including assets and activities) by in\
dividuals other than disqualified
persons. Yes No	
Yes No
Yes No	
b
c b

1	
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INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 20 OF 28
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	20	Form 1023 (Rev. 6-2006) Name: EIN:	
Schedule E. Organizations Not Filing Form 1023 Within 27 Months of Forma\
tion	
2a
Schedule E is intended to determine whether you are eligible for tax exe\
mption under section 501(c)(3) from the postmark date
of your application or from your date of incorporation or formation, whi\
chever is earlier. If you are not eligible for tax exem
ption
under section 501(c)(3) from your date of incorporation or formation\
, Schedule E is also intended to determine whether you are
eligible for tax exemption under section 501(c)(4) for the period be\
tween your date of incorporation or formation and the
postmark date of your application.
Yes No
b
1Are 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.
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 y\
our gross receipts.
If your gross receipts were normally more than $5,000, are you filing th\
is 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.
Were you included as a subordinate in a group exemption application or l\
etter? If “No,” go to line 4.
If you were included as a subordinate in a group exemption letter, are y\
ou filing this application
within 27 months from the date you were notified by the organization hol\
ding the group exemption
letter or the Internal Revenue Service that you cease to be covered by t\
he group exemption letter? If
“Yes,” stop here.
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 t\
he Internal Revenue Service
final adverse ruling letter? If “Yes,” stop here.
Were you created on or before October 9, 1969? If “Yes,” stop here\
. Do not complete the remainder
of this schedule.
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 exemp\
tion. Do you wish to request
an extension of time to apply to be recognized as exempt from the date y\
ou were formed? If “Yes,”
attach a statement explaining why you did not file this application with\
in the 27-month period. Do not
answer lines 6, 7, or 8. If “No,” go to line 6a.
If you answered “No” to line 5, you can only be exempt under secti\
on 501(c)(3) from the postmark
date of this application. Therefore, do you want us to treat this applic\
ation as a request for tax
exemption from the postmark date? If “Yes,” you are eligible for a\
n advance ruling. Complete Part X,
line 6a. If “No,” you will be treated as a private foundation.
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.
3a
b
c
4
5
6a
b Yes No	
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

1	
I.R.S. SPECIFICATIONSTO BE REMOVED BEFORE PRINTING
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INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 21 OF 28
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	21	Form 1023 (Rev. 6-2006) Name: EIN:	
Schedule E. Organizations Not Filing Form 1023 Within 27 Months of Forma\
tion  (Continued)	
7	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 RevenueProjected revenue for 2 years following current tax year
(a) From
To (b)
From
To (c)
Total	
1
2
3
4
5
6
7
8
9
10
11
12
13 Gifts, grants, and contributions received (do
not include unusual grants)
Membership fees received
Gross investment income
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)
Unusual grants
Total revenue. Add lines 10 through 12	
8
According to your answers, you are only eligible for tax exemption under\
 section 501(c)(3) from the
postmark date of your application. However, you may be eligible for tax \
exemption under section
501(c)(4) from your date of formation to the postmark date of the Fo\
rm 1023. Tax exemption under
section 501(c)(4) allows exemption from federal income tax, but gene\
rally not deductibility of
contributions under Code section 170. Check the box at right if you want\
 us to treat this as a
request for exemption under 501(c)(4) from your date of formation to\
 the postmark date.
Attach a completed Page 1 of Form 1024, Application for Recognition of E\
xemption Under Section
501(a), to this application.	

1	
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INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 22 OF 28
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	22	Form 1023 (Rev. 6-2006) Name: EIN:	
Schedule F. Homes for the Elderly or Handicapped and Low-Income Housing	
Section I	General Information About Your Housing	
Yes No	
1
2
3	
Yes No	
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.	
4aProvide a description of each facility.
What is the total number of residents each facility can accommodate?
What is your current number of residents in each facility?
Describe each facility in terms of whether residents rent or purchase ho\
using from you.
Attach a sample copy of your residency or homeownership contract or agre\
ement.
Do you participate in any joint ventures? If “Yes,” state your own\
ership percentage in each joint
venture, list your investment in each joint venture, describe the tax st\
atus of other participants in
each joint venture (including whether they are section 501(c)(3) or\
ganizations), describe the activities
of each joint venture, describe how you exercise control over the activi\
ties of each joint venture, and
describe how each joint venture furthers your exempt purposes. Also, sub\
mit copies of all joint
venture agreements.
Note.  Make sure your answer is consistent with the information provided in Par\
t 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 ho\
w the terms of any contract(s) are
negotiated at arm’s length, and explain how you determine you will pa\
y no more than fair market
value for services.
Note.  Make sure your answer is consistent with the information provided in Par\
t VIII, line 7a.
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 ma\
naged by others, the names of the
persons or organizations that manage or will manage your activities or f\
acilities, 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 servic\
es.
Note.  Answer “Yes” if you do manage or intend to manage your programs th\
rough your own
employees or by using volunteers. Answer “No” if you engage or int\
end to engage a separate
organization or independent contractor. Make sure your answer is consist\
ent with the information
provided in Part VIII, line 7b.
Do you participate in any government housing programs? If “Yes,” d\
escribe these programs.
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.
How did you acquire the facility? For example, did you develop it yourse\
lf, 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.
b
c
d
5
6
7
8
9
10a
b
c Yes No	
Yes No
Yes No
Yes No

1	
I.R.S. SPECIFICATIONSTO BE REMOVED BEFORE PRINTING
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INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 23 OF 28
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	23	Form 1023 (Rev. 6-2006) Name: EIN:	
Schedule F. Homes for the Elderly or Handicapped and Low-Income Housing \
(Continued)	
Section II	Homes for the Elderly or Handicapped	
Yes No	1a
2a
3a	Do you provide housing for the elderly? If “Yes,” describe who qua\
lifies for your housing in terms of
age, infirmity, or other criteria and explain how you select persons for\
 your housing.
4 b
5 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 yo\
u select persons for your
housing.
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 lu\
mp sum or on an installment
basis, whether it is refundable, and the circumstances, if any, under wh\
ich it may be waived.
Do you charge periodic fees or maintenance charges? If “Yes,” desc\
ribe what these charges cover
and how they are determined.
Is your housing affordable to a significant segment of the elderly or ha\
ndicapped persons in the
community? Identify your 
community. Also, if “Yes,” explain how you determine your housing is
affordable. Yes No	
Yes No
Yes No
Yes No	
b
c
Do you have an established policy concerning residents who become unable\
 to pay their regular
charges? If “Yes,” describe your established policy.
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.
Do you have arrangements for the healthcare needs of your residents? If \
“Yes,” describe these
arrangements.
Are your facilities designed to meet the physical, emotional, recreation\
al, social, religious, and/or
other similar needs of the elderly or handicapped? If “Yes,” descr\
ibe these design features.
b	
Yes No
Yes No
Yes No
Yes No	
Section III	Low-Income Housing	
Do you provide low-income housing? If “Yes,” describe who qualifie\
s for your housing in terms of
income levels or other criteria, and describe how you select persons for\
 your housing.
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 determin\
ed.
Is your housing affordable to low income residents? If “Yes,” desc\
ribe how your housing is made
affordable to low-income residents.
Note. 
Revenue Procedure 96-32, 1996-1 C.B. 717, provides guidelines for provid\
ing 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 af\
fordable to low-income
residents? If “Yes,” describe these restrictions.
Do you provide social services to residents? If “Yes,” describe th\
ese services.
1
2
3a
b
4	Yes No
Yes No
Yes No
Yes No
Yes No

1	
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INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 24 OF 28
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PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	24	Form 1023 (Rev. 6-2006) Name: EIN:	
Schedule G. Successors to Other Organizations	
1a
2a
3
4b
5 b
c 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 organ\
ization or converted from
for-profit to nonprofit status.
Are you a successor to an organization other than a for-profit organizat\
ion? Answer “Yes” if you have
taken or will take over the activities of another organization; or you h\
ave taken or will take over 25%
or more of the fair market value of the net assets of another organizati\
on. If “Yes,” explain the
relationship with the other organzation that resulted in your creation.
Provide the tax status of the predecessor organization.
Did you or did an organization to which you are a successor previously a\
pply for tax exemption
under section 501(c)(3) or any other section of the Code? If “Yes\
,” explain how the application was
resolved.
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.
Explain why you took over the activities or assets of another organizati\
on.
Provide the name, last address, and EIN of the predecessor organization \
and describe its activities.
d
e	
Yes No
Yes No
Yes No	
Name:
Address:
EIN:
–
List the owners, partners, principal stockholders, officers, and governi\
ng board members of the predecessor organization.
Attach a separate sheet if additional space is needed.	
Name
AddressShare/Interest (If a for-profit)	
Do or will any of the persons listed in line 4, maintain a working relat\
ionship 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.
Were any assets transferred, whether by gift or sale, from the predecess\
or organization to you?
If “Yes,” provide a list of assets, indicate the value of each ass\
et, 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.
Were any restrictions placed on the use or sale of the assets? If “Ye\
s,” explain the restrictions.
Provide a copy of the agreement(s) of sale or transfer.
Were any debts or liabilities transferred from the predecessor for-profi\
t organization to you?
If “Yes,” provide a list of the debts or liabilities that were tra\
nsferred 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 previously owned or use\
d by the predecessor
for-profit organization, or from persons listed in line 4, or from for-p\
rofit organizations in which these
persons own more than a 35% interest? If “Yes,” submit a copy of t\
he lease or rental agreement(s).
Indicate how the lease or rental value of the property or equipment was \
determined.
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,” att\
ach a list of the property or
equipment, provide a copy of the lease or rental agreement(s), and ind\
icate how the lease or rental
value of the property or equipment was determined.	
6a
bc
7
8
9 Yes No	Yes No
Yes No
Yes No
Yes No
Yes No

1	
I.R.S. SPECIFICATIONSTO BE REMOVED BEFORE PRINTING
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INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 25 OF 28
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PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	25	Form 1023 (Rev. 6-2006) Name: EIN:
Schedule H. Organizations Providing Scholarships, Fellowships, Education\
al Loans, or Other Educational
Grants to Individuals and Private Foundations Requesting Advance Approva\
l 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 char\
ity or a private
foundation.	
1a
2
3	Describe the types of educational grants you provide to individuals, suc\
h as scholarships, fellowships, loans, etc.
4a bc
d
5
6
7 Yes No
Describe the purpose and amount of your scholarships, fellowships, and o\
ther educational grants and loans that you
award.
If you award educational loans, explain the terms of the loans (interes\
t rate, length, forgiveness, etc.).
Specify how your program is publicized.
Provide copies of any solicitation or announcement materials.
Provide a sample copy of the application used.
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, tru\
stees, or donors of funds to you? If
“No,” refer to the instructions.
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 particu\
lar high school who will attend college, writers of
scholarly works about American history, etc.)
Describe the specific criteria you use to select recipients. (For examp\
le, specific selection criteria could consist of prior
academic performance, financial need, etc.)
Describe how you determine the number of grants that will be made annual\
ly.
Describe how you determine the amount of each of your grants.
Describe any requirement or condition that you impose on recipients to o\
btain, maintain, or qualify for renewal of a grant.
(For example, specific requirements or conditions could consist of atte\
ndance at a four-year college, maintaining a certain
grade point average, teaching in public school after graduation from col\
lege, etc.)
Describe your procedures for supervising the scholarships, fellowships, \
educational loans, or other educational grants.
Describe whether you obtain reports and grade transcripts from recipient\
s, or you pay grants directly to a school under
an arrangement whereby the school will apply the grant funds only for en\
rolled 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?
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 measur\
es are taken to
ensure unbiased selections?
Note.  If you are a private foundation, you are not permitted to provide educat\
ional grants to  disqualified
persons. Disqualified persons include your substantial contributors and foundat\
ion managers and
certain family members of disqualified persons.	
b
c
d
e
f
Yes No
Section II	Private foundations complete lines 1a through 4f of this section. Public\
 charities do not
complete this section.	
1a
b
2
3 If we determine that you are a private foundation, do you want this appl\
ication to be
considered as a request for advance approval of grant making procedures?\
For which section(s) do you wish to be considered?
●
4945(g)(1)—Scholarship or fellowship grant to an individual for s\
tudy at an educational institution
● 4945(g)(3)—Other grants, including loans, to an individual for tr\
avel, study, or other similar
purposes, to enhance a particular skill of the grantee or to produce a s\
pecific product
Do you represent that you will (1) arrange to receive and review grant\
ee 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 rea\
sonable and
appropriate steps to recover diverted funds, ensure other grant funds he\
ld by a grantee
are used for their intended purposes, and withhold further payments to g\
rantees until you
obtain grantees’ assurances that future diversions will not occur and\
 that grantees will
take extraordinary precautions to prevent future diversions from occurri\
ng?
Do you represent that you will maintain all records relating to individu\
al 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 th\
at you
undertook the supervision and investigation of grants described in line \
2?	No	N/A	
Yes No
Yes No
Yes

1	
I.R.S. SPECIFICATIONSTO BE REMOVED BEFORE PRINTING
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INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 26 OF 28
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form	1023	(Rev. 6-2006)	
–	Page	26	Form 1023 (Rev. 6-2006) Name: EIN:
Schedule H. Organizations Providing Scholarships, Fellowships, Education\
al Loans, or Other Educational
Grants to Individuals and Private Foundations Requesting Advance Approva\
l 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)	
4a
b
Do you or will you provide scholarships, fellowships, or educational loa\
ns to attend an
educational institution to employees of a particular employer? Do you or will you award scholarships, fellowships, and educational loan\
s 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.
No	
N/A	
Yes No
Yes	
Will you comply with the seven conditions and either the percentage test\
s 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.)\
Do you provide scholarships, fellowships, or educational loans to attend\
 an educational
institution to children of employees of a particular employer?
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 provid\
ed by Revenue
Procedures 76-47 and 80-39?
Note. Statistical or sampling techniques are not acceptable. See Revenue Proce\
dure
85-51, 1985-2 C.B. 717, for additional information.
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 othe\
rwise provide a
significant benefit to the particular employer? If “Yes,” describe\
 the facts and
circumstances that you believe will demonstrate that the grants are neit\
her compensatory
nor a significant benefit to the particular employer. In your explanatio\
n, describe why you
cannot satisfy either the 25% test described in line 4d or the 10% test \
described in line 4e. If “Yes,” will you award grants to 10% or fewer of the eligible ap\
plicants who were
actually considered by the selection committee in selecting recipients o\
f grants in that
year as provided by Revenue Procedures 76-47 and 80-39?
If “Yes,” will you award grants to 25% or fewer of the eligible ap\
plicants who were
actually considered by the selection committee in selecting recipients o\
f grants in that
year as provided by Revenue Procedures 76-47 and 80-39? If “No,” g\
o to line 4e.
If “Yes,” describe how you will determine who can be shown to be e\
ligible for grants
without submitting an application, such as by obtaining written statemen\
ts or other
information about the expectations of employees’ children to attend a\
n educational
institution. If “No,” go to line 4f.
c
d
e
f
No	
N/A	Yes	
No	N/A	Yes	
No	Yes	
No	Yes
Yes No
Yes No

1	
I.R.S. SPECIFICATIONSTO BE REMOVED BEFORE PRINTING
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INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 27 OF 28
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
Form 1023 Checklist
(Revised June 2006)
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. Refe\
r to the  General Instructions
regarding Public Inspection of approved applications.
Check each box to finish your application (Form 1023). Send this compl\
eted Checklist with your filled-in
application. If you have not answered all the items below, your applicat\
ion 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 Sc\
hedule 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 print\
ed materials or publications. Label
each page with name and EIN.
User fee payment placed in envelope on top of checklist. DO NOT STAPLE o\
r otherwise attach your check or
money order to your application. Instead, just place it in the envelope.\
Employer Identification Number (EIN)
Schedules. Submit only those schedules that apply to you and check eithe\
r “Yes” or “No” below.
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 applicat\
ion will prevent us from recognizing
you as tax exempt.
● Describe your purposes and proposed activities in specific easily unders\
tood terms.
● Financial information should correspond with proposed activities.
Schedule A Yes No
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

1	
I.R.S. SPECIFICATIONSTO BE REMOVED BEFORE PRINTING
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
INSTRUCTIONS TO PRINTERS
FORM 1023, PAGE 28 OF 28
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None	
An exact copy of your complete articles of organization (creating docum\
ent). Absence of the proper purpose
and dissolution clauses is the number one reason for delays in the issua\
nce of determination letters.
Signature of an officer, director, trustee, or other official who is aut\
horized to sign the application.
Your name on the application must be the same as your legal name as it a\
ppears in your articles of
organization.
Send completed Form 1023, user fee payment, and all other required infor\
mation, to:
Internal Revenue Service
P.O. Box 192
Covington, KY 41012-0192
If you are using express mail or a delivery service, send Form 1023, use\
r fee payment, and attachments to:
Internal Revenue Service
201 West Rivercenter Blvd.
Attn: Extracting Stop 312
Covington, KY 41011
● Location of Purpose Clause from Part III, line 1 (Page, Article and Par\
agraph Number)
● Location of Dissolution Clause from Part III, line 2b or 2c (Page, Arti\
cle and Paragraph Number) or by
operation of state law
● Signature at Part XI of Form 1023.
Relevant article from our knowledge database

The application has to be complete and accompanied by the right user fee. This application has to be signed and dated. Incomplete applications won't be processed.
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The form has to be signed through an authorized officer, director, ortrustee. Prior to beginning to fill out the form, run via the checklist to make certain you have all the needed documents and data. The form is simply 3 pages long. No, Form 1023 can't be e-filed. The new short form is just 3 pages long, in comparison to the 26-page regular Form.

Foundations can offer employment to adult kids and grandchildren, along with visibility or prestige for individuals involved at elevated levels. Once a foundation is ready to go, there are a number of rules and reporting requirements to stay in mind. As soon as you decide to set up a foundation, there's some preliminary work. If you opt to prepare your foundation for a corporation, you'll need to draft and adopt bylaws. For the large part, you're going to know if you're a private foundation because you'll be preparing the foundation as the primary donor.

To meet the qualifications for an extension inside this circumstance, the organization must demonstrate that its choice to file did not involve hindsight. If it does not have an organizing instrument, it will not qualify for exempt status. If it does not have an organizing document, it will not qualify for exempt status. It needs to affirm that it has the appropriate organizational documents. Eligible organizations aren't required to finish this new shorter form. Nonqualified organizations must still make an application for reinstatement utilizing Form 1023.

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