Form 1023 Application for Exemption under Section 501(c)(3) of the

Form 1023 - Application for Recognition of Exemption Under Section 501(c)(3) of the Internal Revenue Code and Form 1023-EZ, Streamlined

Form 1023 (2017 DRAFT)

Form 1023, Application for Recognition of Exemption Under Section 501(c)(3) of the Internal Revenue Code

OMB: 1545-0056

Document [pdf]

Download: pdf | pdf

▶ Information

▶ Do

December 2017

Form

about Form 1023 and its instructions is available at www.irs.gov/form1023.
not enter SSN numbers on this form as it may be made public if your organization is a 501(c)(3).

1023

(Rev. December 2013)
Department of the Treasury
Internal Revenue Service

Application for Recognition of Exemption
Under Section 501(c)(3) of the Internal Revenue Code
▶ (Use

with the June 2006 revision of the Instructions for Form 1023 and the current Notice 1382)

Version A, Cycle 4

OMB No. 1545-0056
Note. If exempt status is
approved, this
application will be open
for public inspection.

Use the instructions to complete this application and for a definition of all bold items. For additional help, call IRS Exempt
Organizations Customer Account Services toll-free at 1-877-829-5500. Visit our website at www.irs.gov for forms and publications. If
the required information and documents are not submitted with payment of the appropriate user fee, the application may be returned
to you.
Attach additional sheets to this application if you need more space to answer fully. Put your name and EIN on each sheet and
identify each answer by Part and line number. Complete Parts I - XI of Form 1023 and submit only those Schedules (A through H) that
apply to you.

Part I

Identification of Applicant

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

c/o Name (if applicable)

Mailing address (Number and street) (see instructions)

Employer Identification Number (EIN)

Month the annual accounting period ends (01 – 12)

b
c

Phone:
Fax: (optional)

Room/Suite

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

Primary contact (officer, director, trustee, or authorized representative)
a Name:

Internal Use Only
DRAFT AS OF
November 21, 2013

Are you represented by an authorized representative, such as an attorney or accountant? If “Yes,”
provide the authorized representative’s name, and the name and address of the authorized
representative’s firm. Include a completed Form 2848, Power of Attorney and Declaration of
Representative, with your application if you would like us to communicate with your representative.

Yes

Was a person who is not one of your officers, directors, trustees, employees, or an authorized
representative listed in line 7, paid, or promised payment, to help plan, manage, or advise you about
the structure or activities of your organization, or about your financial or tax matters? If “Yes,” provide
the person’s name, the name and address of the person’s firm, the amounts paid or promised to be
paid, and describe that person’s role.

Yes

9 a Organization’s website:

b Organization’s email: (optional)
10
Certain organizations are not required to file an information return (Form 990 or Form 990-EZ). If you
are granted tax-exemption, are you claiming to be excused from filing Form 990 or Form 990-EZ? If
“Yes,” explain. See the instructions for a description of organizations not required to file Form 990 or
Form 990-EZ.
11
12

Date incorporated if a corporation, or formed, if other than a corporation.
Were you formed under the laws of a foreign country?
If “Yes,” state the country.

For Paperwork Reduction Act Notice, see page 24 of the instructions.

Delete

(MM/DD/YYYY)

Cat. No. 17133K

Form

1023

(Rev. 12-2013)

12-2017

12-2017
Form 1023 (Rev. 12-2013)

Part II

Version A, Cycle 4
Name:

EIN:

Page

Organizational Structure

You must be a corporation (including a limited liability company), an unincorporated association, or a trust to be tax exempt.
(See instructions.) DO NOT file this form unless you can check “Yes” on lines 1, 2, 3, or 4.
1

Are you a corporation? If “Yes,” attach a copy of your articles of incorporation showing certification of
filing with the appropriate state agency. Include copies of any amendments to your articles and be sure
they also show state filing certification.

Yes

Are you a limited liability company (LLC)? If “Yes,” attach a copy of your articles of organization showing
certification of filing with the appropriate state agency. Also, if you adopted an operating agreement, attach
a copy. Include copies of any amendments to your articles and be sure they show state filing certification.
Refer to the instructions for circumstances when an LLC should not file its own exemption application.

Yes

Are you an unincorporated association? If “Yes,” attach a copy of your articles of association,
constitution, or other similar organizing document that is dated and includes at least two signatures.
Include signed and dated copies of any amendments.
4 a Are you a trust? If “Yes,” attach a signed and dated copy of your trust agreement. Include signed and
dated copies of any amendments.
b Have you been funded? If “No,” explain how you are formed without anything of value placed in trust.
5
Have you adopted bylaws? If “Yes,” attach a current copy showing date of adoption. If “No,” explain
how your officers, directors, or trustees are selected.

Yes

Yes
Yes

No
No

Part III

Required Provisions in Your Organizing Document

The following questions are designed to ensure that when you file this application, your organizing document contains the required provisions
to meet the organizational test under section 501(c)(3). Unless you can check the boxes in both lines 1 and 2, your organizing document
does not meet the organizational test. DO NOT file this application until you have amended your organizing document. Submit your
original and amended organizing documents (showing state filing certification if you are a corporation or an LLC) with your application.
Section 501(c)(3) requires that your organizing document state your exempt purpose(s), such as charitable,
religious, educational, and/or scientific purposes. Check the box to confirm that your organizing document meets
this requirement. Describe specifically where your organizing document meets this requirement, such as a reference
to a particular article or section in your organizing document. Refer to the instructions for exempt purpose language.

Internal Use Only
DRAFT AS OF
November 21, 2013

Location of Purpose Clause (Page, Article, and Paragraph):
2 a Section 501(c)(3) requires that upon dissolution of your organization, your remaining assets must be used exclusively
for exempt purposes, such as charitable, religious, educational, and/or scientific purposes. Check the box on line 2a to
confirm that your organizing document meets this requirement by express provision for the distribution of assets upon
dissolution. If you rely on state law for your dissolution provision, do not check the box on line 2a and go to line 2c.
b If you checked the box on line 2a, specify the location of your dissolution clause (Page, Article, and Paragraph).
Do not complete line 2c if you checked box 2a.
c See the instructions for information about the operation of state law in your particular state. Check this box if you
rely on operation of state law for your dissolution provision and indicate the state:

Part IV

Narrative Description of Your Activities

Using an attachment, describe your past, present, and planned activities in a narrative. If you believe that you have already provided some of
this information in response to other parts of this application, you may summarize that information here and refer to the specific parts of the
application for supporting details. You may also attach representative copies of newsletters, brochures, or similar documents for supporting
details to this narrative. Remember that if this application is approved, it will be open for public inspection. Therefore, your narrative
description of activities should be thorough and accurate. Refer to the instructions for information that must be included in your description.

Part V
1a

Name

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

List the names, titles, and mailing addresses of all of your officers, directors, and trustees. For each person listed, state their
total annual compensation, or proposed compensation, for all services to the organization, whether as an officer, employee, or
other position. Use actual figures, if available. Enter “none” if no compensation is or will be paid. If additional space is needed,
attach a separate sheet. Refer to the instructions for information on what to include as compensation.
Title

Mailing address

Compensation amount
(annual actual or estimated)

Form

1023

(Rev. 12-2013)

12-2017

Page 3
Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees, Employees,
and Independent Contractors (Continued)

Form 1023 (Rev. 12-2013)

Part V

Version A, Cycle 4
Name:

EIN:

b List the names, titles, and mailing addresses of each of your five highest compensated employees who receive or will receive
compensation of more than $50,000 per year. Use the actual figure, if available. Refer to the instructions for information on
what to include as compensation. Do not include officers, directors, or trustees listed in line 1a.
Name

Title

Compensation amount
(annual actual or estimated)

Mailing address

c List the names, names of businesses, and mailing addresses of your five highest compensated independent contractors that
receive or will receive compensation of more than $50,000 per year. Use the actual figure, if available. Refer to the instructions
for information on what to include as compensation.
Name

Title

Compensation amount
(annual actual or estimated)

Mailing address

Internal Use Only
DRAFT AS OF
November 21, 2013

The following “Yes” or “No” questions relate to past, present, or planned relationships, transactions, or agreements with your officers,
directors, trustees, highest compensated employees, and highest compensated independent contractors listed in lines 1a, 1b, and 1c.
2 a Are any of your officers, directors, or trustees related to each other through family or business
relationships? If “Yes,” identify the individuals and explain the relationship.
b Do you have a business relationship with any of your officers, directors, or trustees other than through
their position as an officer, director, or trustee? If “Yes,” identify the individuals and describe the business
relationship with each of your officers, directors, or trustees.
c Are any of your officers, directors, or trustees related to your highest compensated employees or highest
compensated independent contractors listed on lines 1b or 1c through family or business relationships? If
“Yes,” identify the individuals and explain the relationship.
3 a For each of your officers, directors, trustees, highest compensated employees, and highest
compensated independent contractors listed on lines 1a, 1b, or 1c, attach a list showing their name,
qualifications, average hours worked, and duties.
b Do any of your officers, directors, trustees, highest compensated employees, and highest compensated
independent contractors listed on lines 1a, 1b, or 1c receive compensation from any other organizations,
whether tax exempt or taxable, that are related to you through common control? If “Yes,” identify the
individuals, explain the relationship between you and the other organization, and describe the
compensation arrangement.
4

Yes

Yes
Yes
Yes

No
No
No

In establishing the compensation for your officers, directors, trustees, highest compensated employees,
and highest compensated independent contractors listed on lines 1a, 1b, and 1c, the following practices
are recommended, although they are not required to obtain exemption. Answer “Yes” to all the practices
you use.
a Do you or will the individuals that approve compensation arrangements follow a conflict of interest policy?
b Do you or will you approve compensation arrangements in advance of paying compensation?
c Do you or will you document in writing the date and terms of approved compensation arrangements?
Form

1023

(Rev. 12-2013)

12-2017

Version A, Cycle 4

12-2017
Page 4
Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees, Employees,
and Independent Contractors (Continued)

Form 1023 (Rev. 12-2013)

Part V

Name:

EIN:

d Do you or will you record in writing the decision made by each individual who decided or voted on
compensation arrangements?
e Do you or will you approve compensation arrangements based on information about compensation paid by
similarly situated taxable or tax-exempt organizations for similar services, current compensation surveys
compiled by independent firms, or actual written offers from similarly situated organizations? Refer to the
instructions for Part V, lines 1a, 1b, and 1c, for information on what to include as compensation.

Yes

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

Yes

6 a Do you or will you compensate any of your officers, directors, trustees, highest compensated employees, and highest
compensated independent contractors listed in lines 1a, 1b, or 1c through non-fixed payments, such as discretionary
bonuses or revenue-based payments? If “Yes,” describe all non-fixed compensation arrangements, including how the
amounts are determined, who is eligible for such arrangements, whether you place a limitation on total compensation,
and how you determine or will determine that you pay no more than reasonable compensation for services. Refer to
the instructions for Part V, lines 1a, 1b, and 1c, for information on what to include as compensation.

Yes

b Do you or will you compensate any of your employees, other than your officers, directors, trustees, or your
five highest compensated employees who receive or will receive compensation of more than $50,000 per
year, through non-fixed payments, such as discretionary bonuses or revenue-based payments? If “Yes,”
describe all non-fixed compensation arrangements, including how the amounts are or will be determined, who
is or will be eligible for such arrangements, whether you place or will place a limitation on total compensation,
and how you determine or will determine that you pay no more than reasonable compensation for services.
Refer to the instructions for Part V, lines 1a, 1b, and 1c, for information on what to include as compensation.

Yes

7 a Do you or will you purchase any goods, services, or assets from any of your officers, directors, trustees, highest
compensated employees, or highest compensated independent contractors listed in lines 1a, 1b, or 1c? If “Yes,”
describe any such purchase that you made or intend to make, from whom you make or will make such purchases, how
the terms are or will be negotiated at arm’s length, and explain how you determine or will determine that you pay no
more than fair market value. Attach copies of any written contracts or other agreements relating to such purchases.

Yes

b Do you or will you sell any goods, services, or assets to any of your officers, directors, trustees, highest
compensated employees, or highest compensated independent contractors listed in lines 1a, 1b, or 1c? If “Yes,”
describe any such sales that you made or intend to make, to whom you make or will make such sales, how the
terms are or will be negotiated at arm’s length, and explain how you determine or will determine you are or will be
paid at least fair market value. Attach copies of any written contracts or other agreements relating to such sales.

Yes

8 a Do you or will you have any leases, contracts, loans, or other agreements with your officers, directors,
trustees, highest compensated employees, or highest compensated independent contractors listed in
lines 1a, 1b, or 1c? If “Yes,” provide the information requested in lines 8b through 8f.

Yes

g If you answered “No” to any item on lines 4a through 4f, describe how you set compensation that is
reasonable for your officers, directors, trustees, highest compensated employees, and highest
compensated independent contractors listed in Part V, lines 1a, 1b, and 1c.
5 a 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.
b What procedures will you follow to assure that persons who have a conflict of interest will not have
influence over you for setting their own compensation?
c What procedures will you follow to assure that persons who have a conflict of interest will not have
influence over you regarding business deals with themselves?
Note. A conflict of interest policy is recommended though it is not required to obtain exemption.
Hospitals, see Schedule C, Section I, line 14.

Internal Use Only
DRAFT AS OF
November 21, 2013

b
c
d
e
f

Describe any written or oral arrangements that you made or intend to make.
Identify with whom you have or will have such arrangements.
Explain how the terms are or will be negotiated at arm’s length.
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 agreements relating to such arrangements.

9 a Do you or will you have any leases, contracts, loans, or other agreements with any organization in which
any of your officers, directors, or trustees are also officers, directors, or trustees, or in which any
individual officer, director, or trustee owns more than a 35% interest? If “Yes,” provide the information
requested in lines 9b through 9f.
Form

1023

(Rev. 12-2013)

12-2017

12-2017
Form 1023 (Rev. 12-2013)

Part V

Version A, Cycle 4
Name:

EIN:

Page

b
c
d
e

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 market value or that you are paid
at least fair market value.

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

Part VI

Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees,
Employees, and Independent Contractors (Continued)

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

The following “Yes” or “No” questions relate to goods, services, and funds you provide to individuals and organizations as part of your
activities. Your answers should pertain to past, present, and planned activities. (See instructions.)
1 a In carrying out your exempt purposes, do you provide goods, services, or funds to individuals? If “Yes,”
describe each program that provides goods, services, or funds to individuals.
b In carrying out your exempt purposes, do you provide goods, services, or funds to organizations? If
“Yes,” describe each program that provides goods, services, or funds to organizations.

Yes

Do any of your programs limit the provision of goods, services, or funds to a specific individual or group
of specific individuals? For example, answer “Yes,” if goods, services, or funds are provided only for a
particular individual, your members, individuals who work for a particular employer, or graduates of a
particular school. If “Yes,” explain the limitation and how recipients are selected for each program.

Yes

Do any individuals who receive goods, services, or funds through your programs have a family or
business relationship with any officer, director, trustee, or with any of your highest compensated
employees or highest compensated independent contractors listed in Part V, lines 1a, 1b, and 1c? If
“Yes,” explain how these related individuals are eligible for goods, services, or funds.

Yes

Part VII

Internal Use Only
DRAFT AS OF
November 21, 2013
Your History

The following “Yes” or “No” questions relate to your history. (See instructions.)
1
Are you a successor to another organization? Answer “Yes,” if you have taken or will take over the
activities of another organization; you took over 25% or more of the fair market value of the net assets of
another organization; or you were established upon the conversion of an organization from for-profit to
non-profit status. If “Yes,” complete Schedule G.
2

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.

Part VIII

Yes

Your Specific Activities

The following “Yes” or “No” questions relate to specific activities that you may conduct. Check the appropriate box. Your answers
should pertain to past, present, and planned activities. (See instructions.)
1
Do you support or oppose candidates in political campaigns in any way? If “Yes,” explain.
Yes
No
2 a Do you attempt to influence legislation? If “Yes,” explain how you attempt to influence legislation and
Yes
No
complete line 2b. If “No,” go to line 3a.
Yes
No
b Have you made or are you making an election to have your legislative activities measured by
expenditures by filing Form 5768? If “Yes,” attach a copy of the Form 5768 that was already filed or
attach a completed Form 5768 that you are filing with this application. If “No,” describe whether your
attempts to influence legislation are a substantial part of your activities. Include the time and money
spent on your attempts to influence legislation as compared to your total activities.
3 a Do you or will you operate bingo or gaming activities? If “Yes,” describe who conducts them, and list all
revenue received or expected to be received and expenses paid or expected to be paid in operating
these activities. Revenue and expenses should be provided for the time periods specified in Part IX,
Financial Data.

Yes

b Do you or will you enter into contracts or other agreements with individuals or organizations to conduct
bingo or gaming for you? If “Yes,” describe any written or oral arrangements that you made or intend to
make, identify with whom you have or will have such arrangements, explain how the terms are or will be
negotiated at arm’s length, and explain how you determine or will determine you pay no more than fair
market value or you will be paid at least fair market value. Attach copies or any written contracts or other
agreements relating to such arrangements.

Yes

c List the states and local jurisdictions, including Indian Reservations, in which you conduct or will conduct
gaming or bingo.
Form

1023

(Rev. 12-2013)

12-2017

12-2017
Form 1023 (Rev. 12-2013)

Part VIII

Version A, Cycle 4
Name:

EIN:

Page

Your Specific Activities (Continued)

4 a Do you or will you undertake fundraising? If “Yes,” check all the fundraising programs you do or will
conduct. (See instructions.)
mail solicitations
email solicitations
personal solicitations
vehicle, boat, plane, or similar donations
foundation grant solicitations

Yes

phone solicitations
accept donations on your website
receive donations from another organization’s website
government grant solicitations
Other

Attach a description of each fundraising program.
b Do you or will you have written or oral contracts with any individuals or organizations to raise funds for
you? If “Yes,” describe these activities. Include all revenue and expenses from these activities and state
who conducts them. Revenue and expenses should be provided for the time periods specified in Part IX,
Financial Data. Also, attach a copy of any contracts or agreements.

Yes

c Do you or will you engage in fundraising activities for other organizations? If “Yes,” describe these
arrangements. Include a description of the organizations for which you raise funds and attach copies of
all contracts or agreements.

Yes

d List all states and local jurisdictions in which you conduct fundraising. For each state or local jurisdiction
listed, specify whether you fundraise for your own organization, you fundraise for another organization, or
another organization fundraises for you.
e Do you or will you maintain separate accounts for any contributor under which the contributor has the
right to advise on the use or distribution of funds? Answer “Yes” if the donor may provide advice on the
types of investments, distributions from the types of investments, or the distribution from the donor’s
contribution account. If “Yes,” describe this program, including the type of advice that may be provided
and submit copies of any written materials provided to donors.

Internal Use Only
DRAFT AS OF
November 21, 2013

5
Are you affiliated with a governmental unit? If “Yes,” explain.
6 a Do you or will you engage in economic development? If “Yes,” describe your program.
b Describe in full who benefits from your economic development activities and how the activities promote
exempt purposes.

Yes
Yes

No
No

7 a Do or will persons other than your employees or volunteers develop your facilities? If “Yes,” describe
each facility, the role of the developer, and any business or family relationship(s) between the developer
and your officers, directors, or trustees.

Yes

b Do or will persons other than your employees or volunteers manage your activities or facilities? If “Yes,”
describe each activity and facility, the role of the manager, and any business or family relationship(s)
between the manager and your officers, directors, or trustees.

Yes

Do you or will you enter into joint ventures, including partnerships or limited liability companies
treated as partnerships, in which you share profits and losses with partners other than section 501(c)(3)
organizations? If “Yes,” describe the activities of these joint ventures in which you participate.
9 a 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.
b 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 childcare organization described in
section 501(k).

Yes

c 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 instructions)? If “No,” explain how you qualify as
a childcare organization described in section 501(k).

Yes

d Are your services available to the general public? If “No,” describe the specific group of people for whom
your activities are available. Also, see the instructions and explain how you qualify as a childcare
organization described in section 501(k).

Yes

Do you or will you publish, own, or have rights in music, literature, tapes, artworks, choreography,
scientific discoveries, or other intellectual property? If “Yes,” explain. Describe who owns or will own
any copyrights, patents, or trademarks, whether fees are or will be charged, how the fees are
determined, and how any items are or will be produced, distributed, and marketed.

Yes

c If there is a business or family relationship between any manager or developer and your officers,
directors, or trustees, identify the individuals, explain the relationship, describe how contracts are
negotiated at arm’s length so that you pay no more than fair market value, and submit a copy of any
contracts or other agreements.
8

Form

1023

(Rev. 12-2013)

12-2017

Form 1023 (Rev. 12-2013)

Part VIII
11

Version A, Cycle 4
Name:

EIN:

Page

Do you or will you accept contributions of: real property; conservation easements; closely held
securities; intellectual property such as patents, trademarks, and copyrights; works of music or art;
licenses; royalties; automobiles, boats, planes, or other vehicles; or collectibles of any type? If “Yes,”
describe each type of contribution, any conditions imposed by the donor on the contribution, and any
agreements with the donor regarding the contribution.

Yes

12 a Do you or will you operate in a foreign country or countries? If “Yes,” answer lines 12b through 12d. If
“No,” go to line 13a.
b Name the foreign countries and regions within the countries in which you operate.
c Describe your operations in each country and region in which you operate.
d Describe how your operations in each country and region further your exempt purposes.
13 a Do you or will you make grants, loans, or other distributions to organization(s)? If “Yes,” answer lines 13b
through 13g. If “No,” go to line 14a.

Yes

Yes
Yes

No
No

b
c
d
e
f

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 “Yes,” 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 other distributions you make.
Describe your selection process, including whether you do any of the following:
(i) Do you require an application form? If “Yes,” attach a copy of the form.
(ii) Do you require a grant proposal? If “Yes,” describe whether the grant proposal specifies your
responsibilities and those of the grantee, obligates the grantee to use the grant funds only for the
purposes for which the grant was made, provides for periodic written reports concerning the use of
grant funds, requires a final written report and an accounting of how grant funds were used, and
acknowledges your authority to withhold and/or recover grant funds in case such funds are, or appear
to be, misused.

Internal Use Only
DRAFT AS OF
November 21, 2013

g Describe your procedures for oversight of distributions that assure you the resources are used to further
your exempt purposes, including whether you require periodic and final reports on the use of resources.
14 a Do you or will you make grants, loans, or other distributions to foreign organizations? If “Yes,” answer
lines 14b through 14f. If “No,” go to line 15.
b Provide the name of each foreign organization, the country and regions within a country in which each
foreign organization operates, and describe any relationship you have with each foreign organization.
c Does any foreign organization listed in line 14b accept contributions earmarked for a specific country or
specific organization? If “Yes,” list all earmarked organizations or countries.
d Do your contributors know that you have ultimate authority to use contributions made to you at your
discretion for purposes consistent with your exempt purposes? If “Yes,” describe how you relay this
information to contributors.

Yes

e Do you or will you make pre-grant inquiries about the recipient organization? If “Yes,” describe these
inquiries, including whether you inquire about the recipient’s financial status, its tax-exempt status under
the Internal Revenue Code, its ability to accomplish the purpose for which the resources are provided,
and other relevant information.

Yes

Do you or will you use any additional procedures to ensure that your distributions to foreign
organizations are used in furtherance of your exempt purposes? If “Yes,” describe these procedures,
including site visits by your employees or compliance checks by impartial experts, to verify that grant
funds are being used appropriately.

Yes

Your Specific Activities (Continued)

Form

1023

(Rev. 12-2013)

12-2017

Version A, Cycle 4

12-2017
Form 1023 (Rev. 12-2013)

Part VIII
15
16
17
18
19
20
21
22

Name:

EIN:

Page

Your Specific Activities (Continued)

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.
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.
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.
Do you or will you provide scholarships, fellowships, educational loans, or other educational grants to
individuals, including grants for travel, study, or other similar purposes? If “Yes,” complete Schedule H.
Note. Private foundations may use Schedule H to request advance approval of individual grant
procedures.

Yes
Yes

No
No

Yes

Yes
Yes

No
No

Yes
Yes

No
No

Yes

Internal Use Only
DRAFT AS OF
November 21, 2013

Form

1023

(Rev. 12-2013)

12-2017

Form 1023 (Rev. 12-2013)

Part IX

Version A, Cycle 4
Name:

EIN:

Page

Financial Data

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 year but less than 4 years, complete the statements for each year in
existence and provide projections of your likely revenues and expenses based on a reasonable and good faith estimate of your future
finances for a total of 3 years of financial information. If in existence less than 1 year, provide projections of your likely revenues and
expenses for the current year and the 2 following years, based on a reasonable and good faith estimate of your future finances for a
total of 3 years of financial information. (See instructions.)
A. Statement of Revenues and Expenses
Type of revenue or expense

Current tax year
(a) From
To

3 prior tax years or 2 succeeding tax years
(b) From
To

(d) From
To

(e) Provide Total for
(a) through (d)

Revenues

1 Gifts, grants, and
contributions received (do not
include unusual grants)
2 Membership fees received
3 Gross investment income
4 Net unrelated business
income
5 Taxes levied for your benefit
6 Value of services or facilities
furnished by a governmental
unit without charge (not
including the value of services
generally furnished to the public
without charge)

Internal Use Only
DRAFT AS OF
November 21, 2013

7 Any revenue not otherwise listed
above or in lines 9–12 below
(attach an itemized list)
8 Total of lines 1 through 7
9 Gross receipts from admissions,
merchandise sold or services
performed, or furnishing of
facilities in any activity that is
related to your exempt
purposes (attach itemized list)
10 Total of lines 8 and 9
11 Net gain or loss on sale of
capital assets (attach
schedule and see instructions)
12 Unusual grants
13 Total Revenue
Add lines 10 through 12
14 Fundraising expenses
15 Contributions, gifts, grants,
and similar amounts paid out
(attach an itemized list)

Expenses

16 Disbursements to or for the
benefit of members (attach an
itemized list)
17 Compensation of officers,
directors, and trustees
18 Other salaries and wages
19 Interest expense
20 Occupancy (rent, utilities, etc.)
21 Depreciation and depletion
22 Professional fees
23 Any expense not otherwise
classified, such as program
services (attach itemized list)
24 Total Expenses
Add lines 14 through 23
Form

1023

(Rev. 12-2013)

12-2017

Version A, Cycle 4

12-2017
Form 1023 (Rev. 12-2013)

Part IX

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

Name:

EIN:

B. Balance Sheet (for your most recently completed tax year)
Assets
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 since the end of the period
shown above? If “Yes,” explain.

Part X

Page

Financial Data (Continued)
Year End:

(Whole dollars)
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.

1
2
3
4
5
6
7
8
9
10
11

.
.
.
.
.

12
13
14
15
16

.
.

17
18
Yes

Internal Use Only
DRAFT AS OF
November 21, 2013
Public Charity Status

Part X is designed to classify you as an organization that is either a private foundation or a public charity. Public charity status is a
more favorable tax status than private foundation status. If you are a private foundation, Part X is designed to further determine
whether you are a private operating foundation. (See instructions.)
1 a Are you a private foundation? If “Yes,” go to line 1b. If “No,” go to line 5 and proceed as instructed. If you
are unsure, see the instructions.

Yes

b As a private foundation, section 508(e) requires special provisions in your organizing document in
addition to those that apply to all organizations described in section 501(c)(3). Check the box to confirm
that your organizing document meets this requirement, whether by express provision or by reliance on
operation of state law. Attach a statement that describes specifically where your organizing document
meets this requirement, such as a reference to a particular article or section in your organizing document
or by operation of state law. See the instructions, including Appendix B, for information about the special
provisions that need to be contained in your organizing document. Go to line 2.
2

Are you a private operating foundation? To be a private operating foundation you must engage directly in
the active conduct of charitable, religious, educational, and similar activities, as opposed to indirectly
carrying out these activities by providing grants to individuals or other organizations. If “Yes,” go to line 3.
If “No,” go to the signature section of Part XI.

Yes

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, (including a written affidavit or opinion
from a certified public accountant or accounting firm with expertise regarding this tax law matter), that
sets forth facts concerning your operations and support to demonstrate that you are likely to satisfy the
requirements to be classified as a private operating foundation; or (2) a statement describing your
proposed operations as a private operating foundation?

Yes

If you answered “No” to line 1a, indicate the type of public charity status you are requesting by checking one of the choices
below. You may check only one box.
The organization is not a private foundation because it is:
a 509(a)(1) and 170(b)(1)(A)(i)—a church or a convention or association of churches. Complete and attach Schedule A.
b 509(a)(1) and 170(b)(1)(A)(ii)—a school. Complete and attach Schedule B.
c 509(a)(1) and 170(b)(1)(A)(iii)—a hospital, a cooperative hospital service organization, or a medical research
organization operated in conjunction with a hospital. Complete and attach Schedule C.
d 509(a)(3)—an organization supporting either one or more organizations described in line 5a through c, f, g, or h or a
publicly supported section 501(c)(4), (5), or (6) organization. Complete and attach Schedule D.
Form

1023

(Rev. 12-2013)

12-2017

12-2017
Form 1023 (Rev. 12-2013)

Part X

Version A, Cycle 4
Name:

EIN:

Page

Public Charity Status (Continued)

e 509(a)(4)—an organization organized and operated exclusively for testing for public safety.
f 509(a)(1) and 170(b)(1)(A)(iv)—an organization operated for the benefit of a college or university that is owned or
Part X Publicoperated
Charity by
Status
(Continued)
a governmental
unit.
e 509(a)(4)g - 509(a)(1)
an organization
organized
and
operated
exclusively
for testing
for public safety.
☐
and 170(b)(1)(A)(vi)—an
organization
that receives
a substantial
part of its financial support in the form of
f 509(a)(1) and
170(b)(1)(A)(iv)
- an organization
for the from
benefit
of a college orunit,
university
that
owned public.
or operated by a governmental
contributions
from publicly
supportedoperated
organizations,
a governmental
or from
theisgeneral
unit.
☐
h 509(a)(2)—an organization that normally receives not more than one-third of its financial support from gross
g 509(a)(1) and 170(b)(1)(A)(ix) - an agricultural research organization directly engaged in the continuous active conduct of agricultural research in
investment income and receives more than one-third of its financial support from contributions, membership fees,
conjunction with a college or university.
☐
and gross receipts from activities related to its exempt functions (subject to certain exceptions).
h 509(a)(1) and 170(b)(1)(A)(vi) -an organization that receives a substantial part of its financial support in the form of contributions from publicly
A publicly supported
organization,unit,
but or
unsure
if it general
is described
i organizations,
supported
from a governmental
from the
public.in 5g or 5h. The organization would like the IRS to
☐
the correct
i 509(a)(2) - decide
an organization
thatstatus.
normally receives not more than one-third of its financial support from gross investment income and receives
If you checked
box g, support
h, or i from
in question
5 above,
you must fees,
request
advance
a definitive
ruling
6 one-third
more than
of its financial
contributions,
membership
andeither
grossan
receipts
fromoractivities
related
to its by
exempt functions
selecting
one of the boxes below. Refer to the instructions to determine which type of ruling you are eligible to receive.
(subject to certain
exceptions).
☐
a supported
Request organization,
for Advancebut
Ruling:
Byifchecking
this box
signing
the consent,
to section
6501(c)(4)
of the
j A publicly
unsure
it is described
in 2hand
or 2i.
You would
like thepursuant
IRS to decide
the correct
status.
☐
Code
an advance
rulingand
andyou
agree
to been
extend
the statutemore
of limitations
on theyou
assessment
of excise
tax support status.
6 If you checked
boxyou
h, i,request
or j in question
5 above,
have
in existence
than five years,
must confirm
your public
Answer lineunder
6a if you
checked
in Code.
line 5 above.
lineonly
6b ififyou
box i in line
5 above.
If you
checked
j inofline 5 above,
section
4940box
of hthe
The taxAnswer
will apply
youchecked
do not establish
public
support
status
at thebox
end
answer boththe
lines
6a and
6b. ruling period. The assessment period will be extended for the 5 advance ruling years to 8 years,
5-year
advance
4 months, and 15 days beyond the end of the first year. You have the right to refuse or limit the extension to a
a (i) Entermutually
2% of line
8, column (e)
on Part
IX-A or
Statement
Revenues1035,
and Expenses
agreed-upon
period
of time
issue(s). of
Publication
Extending_____________________
the Tax Assessment Period, provides a
(ii) Attachmore
a list detailed
showing the
name andofamount
contributed
by each
person, company,
organization
whose gifts
more than the 2%
explanation
your rights
and the
consequences
of the orchoices
you make.
You totaled
may obtain
amount.
If the answer
is “None”,
statefrom
this.the IRS web site at www.irs.gov or by calling toll-free 1-800-829-3676. Signing
Publication
1035 free
of charge
b (i) For each
year amounts
aredeprive
included
onoflines
2, andrights
9 of Part
IX-A you
Statement
Revenues
Expenses,
list showing
the name
this consent
will not
you
any 1,
appeal
to which
would ofotherwise
beand
entitled.
If youattach
decidea not
to
and amount
from
each disqualified
If the
is “None”,
extend received
the statute
of limitations,
you areperson.
not eligible
foranswer
an advance
ruling.state this.
(ii) For each year amounts were included on line 9 of Part IX-A Statement of Revenues and Expenses, attach a list showing the name of and
amount received from each payer, other than a disqualified person, whose payments were more than the larger of (1) 1% of Line 10,
Consent Fixing Period of Limitations Upon Assessment of Tax Under Section 4940 of the Internal Revenue Code
Part IX-A Statement of Revenues and Expenses, or (2) $5,000. If the answer is “None”, state this.
7 Did you receive any unusual grants during any of the years shown on Part IX-A Statement of Revenues and Expenses? If “Yes”, attach a list
including the name
of the contributor, the date and amount of the grant, a brief description of the grant, and explain why it is unusual. ☐ Yes ☐ No
For Organization

Internal Use Only
DRAFT AS OF
November 21, 2013

Part XI User Fee Information and Signature

You must include the correct user fee payment with this application. If you do not submit the correct user fee, we will not process the application and
we will return it to you.
Your check or money order must be made (Type
payable
to the United States Treasury. User fees are
subject to change. Check our
(Signature of Officer, Director, Trustee, or other
(Date)
or print name of signer)
website at www.irs.gov
and
type
“Exempt
Organizations
User
Fee”
in
the
search
box,
or
call
Customer
Account
Services
at 1-877-829-5500 for current
authorized official)
information.
Enter the amount of the user fee paid: __________________________
(Typeonorbehalf
print title
or authority
of signer)
I declare under the penalties of perjury that I am authorized to sign this application
of the
above organization
and that I have examined this application, including the
accompanying schedules and attachments, and to the best of my knowledge it is true, correct, and complete.

Please
Sign
Here
_______________________________
For IRS Use Only

IRS Director, Exempt Organizations

_____________________________

(Date)

__________________

(Signature of Officer, Director, Trustee, or
(Type or print name of signer)
(Date)
b Request for
Definitive Ruling: Check this box if you have
completed one tax year of at least 8 full months
and you
other authorized individual)
are requesting a definitive ruling. To confirm your public support
status, answer line 6b(i) if you checked box g in line
______________________________________
5 above. Answer line 6b(ii) if you checked box h in line (Type
5 above.
you
checked
box i in line 5 above, answer both
or printIftitle
or authority
of signer)
lines 6b(i) and (ii).
Form 1023 (Rev. 12-2017)

(i) (a) Enter 2% of line 8, column (e) on Part IX-A. Statement of Revenues and Expenses.
(b) Attach a list showing the name and amount contributed by each person, company, or organization whose
gifts totaled more than the 2% amount. If the answer is “None,” check this box.
(ii) (a) For each year amounts are included on lines 1, 2, and 9 of Part IX-A. Statement of Revenues and Expenses,
attach a list showing the name of and amount received from each disqualified person. If the answer is
“None,” check this box.
(b) 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 than a disqualified person, whose
payments were more than the larger of (1) 1% of line 10, Part IX-A. Statement of Revenues and Expenses, or
(2) $5,000. If the answer is “None,” check this box.
7

Did you receive any unusual grants during any of the years shown on Part IX-A. Statement of Revenues
and Expenses? If “Yes,” attach a list including the name of the contributor, the date and amount of the
grant, a brief description of the grant, and explain why it is unusual.
Form

Yes

1023

(Rev. 12-2013)

12-2017

Name:

Version A, Cycle 4

Delete

"This page is intentionally left blank."

Form 1023 (Rev. 12-2013)

Part XI

Composition: This page should ONLY state

Delete

12-2017

EIN:

Page

User Fee Information

You must include a user fee payment with this application. It will not be 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 $850. If your gross
receipts have not exceeded or will not exceed $10,000 annually over a 4-year period, the required user fee payment is $400. 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 type “User Fee” in the keyword
box, or call Customer Account Services at 1-877-829-5500 for current information.
1

2
3

Yes

Have your annual gross receipts averaged or are they expected to average not more than $10,000?
If “Yes,” check the box on line 2 and enclose a user fee payment of $400 (Subject to change—see above).
If “No,” check the box on line 3 and enclose a user fee payment of $850 (Subject to change—see above).
Check the box if you have enclosed the reduced user fee payment of $400 (Subject to change).
Check the box if you have enclosed the user fee payment of $850 (Subject to change).

I declare under the penalties of perjury that I am authorized to sign this application on behalf of the above organization and that I have examined this application,
including the accompanying schedules and attachments, and to the best of my knowledge it is true, correct, and complete.
▲

Please
Sign
Here

(Signature of Officer, Director, Trustee, or other
authorized official)

(Type or print name of signer)

(Date)

(Type or print title or authority of signer)

Reminder: Send the completed Form 1023 Checklist with your filled-in-application.

Form

1023

(Rev. 12-2013)

12-2017

Internal Use Only
DRAFT AS OF
November 21, 2013

Version A, Cycle 4

12-2017
Form 1023 (Rev. 12-2013)

Name:

EIN:

Page

Schedule A. Churches

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

Yes

b Do you have a form of worship? If “Yes,” describe your form of worship.
2 a Do you have a formal code of doctrine and discipline? If “Yes,” describe your code of doctrine and
discipline.

Yes
Yes

No
No

b Do you have a distinct religious history? If “Yes,” describe your religious history.

Yes

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

Yes

4 a Do you have regularly scheduled religious services? If “Yes,” describe the nature of the services and
provide representative copies of relevant literature such as church bulletins.

Yes

b What is the average attendance at your regularly scheduled religious services?
5 a Do you have an established place of worship? If “Yes,” refer to the instructions for the information
required.

Yes

b Do you own the property where you have an established place of worship?
Do you have an established congregation or other regular membership group? If “No,” refer to the
instructions.

Yes
Yes

No
No

Describe the organization’s religious hierarchy or ecclesiastical government.

Internal Use Only
DRAFT AS OF
November 21, 2013

7
How many members do you have?
8 a Do you have a process by which an individual becomes a member? If “Yes,” describe the process and
complete lines 8b–8d, below.
b If you have members, do your members have voting rights, rights to participate in religious functions, or
other rights? If “Yes,” describe the rights your members have.

Yes

c May your members be associated with another denomination or church?

Yes

d Are all of your members part of the same family?

Yes

Yes
Yes

No
No

Yes

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

Yes
Yes

No
No

Yes

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

Yes

16
17

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.

Yes
Yes

No
No

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

10
Do you have a school for the religious instruction of the young?
11 a Do you have a minister or religious leader? If “Yes,” describe this person’s role and explain whether the
minister or religious leader was ordained, commissioned, or licensed after a prescribed course of study.
b Do you have schools for the preparation of your ordained ministers or religious leaders?
12
13
14

Form

1023

(Rev. 12-2013)

12-2017

Form 1023 (Rev. 12-2013)

Version A, Cycle 4
Name:

EIN:

Page

Schedule B. Schools, Colleges, and Universities
If you operate a school as an activity, complete Schedule B

Section I

Operational Information

1 a Do you normally have a regularly scheduled curriculum, a regular faculty of qualified teachers, a regularly
enrolled student body, and facilities where your educational activities are regularly carried on? If “No,” do
not complete the remainder of Schedule B.

Yes

b Is the primary function of your school the presentation of formal instruction? If “Yes,” describe your
school in terms of whether it is an elementary, secondary, college, technical, or other type of school. If
“No,” do not complete the remainder of Schedule B.

Yes

2 a Are you a public school because you are operated by a state or subdivision of a state? If “Yes,” explain
how you are operated by a state or subdivision of a state. Do not complete the remainder of Schedule B.
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 predominantly from government funds or
property. Submit a copy of your funding agreement regarding government funding. Do not complete the
remainder of Schedule B.

Yes

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

Were you formed or substantially expanded at the time of public school desegregation in the above
school district or county?
Has a state or federal administrative agency or judicial body ever determined that you are racially
discriminatory? If “Yes,” explain.
Has your right to receive financial aid or assistance from a governmental 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.

5
6
7

Internal Use Only
DRAFT AS OF
November 21, 2013

Note. Make sure your answer is consistent with the information provided in Part VIII, line 7a.
8

Do you or will you manage your activities or facilities through your own employees or volunteers? If “No,”
attach a statement describing the activities that will be managed by others, the names of the persons or
organizations that manage or will manage your activities or facilities, and how these managers were or
will be selected. Also, submit copies of any contracts, proposed contracts, or other agreements
regarding the provision of management services for your activities or facilities. Explain how the terms of
any contracts or other agreements were or will be negotiated, and explain how you determine you will
pay no more than fair market value for services.
Note. Answer “Yes” if you manage or intend to manage your programs through your own employees or
by using volunteers. Answer “No” if you engage or intend to engage a separate organization or
independent contractor. Make sure your answer is consistent with the information provided in Part VIII,
line 7b.

Section II
1

Establishment of Racially Nondiscriminatory Policy

Information required by Revenue Procedure 75-50.

Have you adopted a racially nondiscriminatory policy as to students in your organizing document,
bylaws, or by resolution of your governing body? If “Yes,” state where the policy can be found or supply
a copy of the policy. If “No,” you must adopt a nondiscriminatory policy as to students before submitting
this application. See Publication 557.
Do your brochures, application forms, advertisements, and catalogues dealing with student admissions,
programs, and scholarships contain a statement of your racially nondiscriminatory policy?
a If “Yes,” attach a representative sample of each document.
b If “No,” by checking the box to the right you agree that all future printed materials, including website
content, will contain the required nondiscriminatory policy statement.

▶

Have you published a notice of your nondiscriminatory policy in a newspaper of general circulation that
serves all racial segments of the community? (See the instructions for specific requirements.) If “No,”
explain.

Yes

Does or will the organization (or any department or division within it) discriminate in any way on the basis
of race with respect to admissions; use of facilities or exercise of student privileges; faculty or
administrative staff; or scholarship or loan programs? If “Yes,” for any of the above, explain fully.

Yes

Form

1023

(Rev. 12-2013)

12-2017

Version A, Cycle 4

12-2017
Form 1023 (Rev. 12-2013)

Name:

EIN:

Page

Schedule B. Schools, Colleges, and Universities (Continued)
5

Complete the table below to show the racial composition for the current academic year and projected for the next academic
year, of: (a) the student body, (b) the faculty, and (c) the administrative staff. Provide actual numbers rather than percentages
for each racial category.
If you are not operational, submit an estimate based on the best information available (such as the racial composition of the
community served).
Racial Category
(a) Student Body
(b) Faculty
(c) Administrative Staff
Next Year
Next Year
Next Year
Current Year
Current Year
Current Year

Total
6

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

Number of Loans
Amount of Loans
Number of Scholarships Amount of Scholarships
Next
Year
Current Year
Current Year Next Year Current Year Next Year Current Year Next Year

Internal Use Only
DRAFT AS OF
November 21, 2013

Total

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

b Do any of these individuals or organizations have an objective to maintain segregated public or private
school education? If “Yes,” explain.

Yes

Will you maintain records according to the non-discrimination provisions contained in Revenue
Procedure 75-50? If “No,” explain. (See instructions.)

Yes

Form

1023

(Rev. 12-2013)

12-2017

12-2017
Form 1023 (Rev. 12-2013)

Version A, Cycle 4
Name:

EIN:

Page

Schedule C. Hospitals and Medical Research Organizations
Check the box if you are a hospital. See the instructions for a definition of the term “hospital,” which includes an
organization whose principal purpose or function is providing hospital or medical care. Complete Section I below.
Check the box if you are a medical research organization operated in conjunction with a hospital. See the instructions for
a definition of the term “medical research organization,” which refers to an organization whose principal purpose or
function is medical research and which is directly engaged in the continuous active conduct of medical research in
conjunction with a hospital. Complete Section II.

Section I

Hospitals

1 a Are all the doctors in the community eligible for staff privileges? If “No,” give the reasons why and
explain how the medical staff is selected.
2 a Do you or will you provide medical services to all individuals in your community who can pay for
themselves or have private health insurance? If “No,” explain.
b Do you or will you provide medical services to all individuals in your community who participate in
Medicare? If “No,” explain.
c Do you or will you provide medical services to all individuals in your community who participate in
Medicaid? If “No,” explain.
3 a Do you or will you require persons covered by Medicare or Medicaid to pay a deposit before receiving
services? If “Yes,” explain.
b Does the same deposit requirement, if any, apply to all other patients? If “No,” explain.
4 a Do you or will you maintain a full-time emergency room? If “No,” explain why you do not maintain a
full-time emergency room. Also, describe any emergency services that you provide.
b Do you have a policy on providing emergency services to persons without apparent means to pay? If
“Yes,” provide a copy of the policy.
c Do you have any arrangements with police, fire, and voluntary ambulance services for the delivery or
admission of emergency cases? If “Yes,” describe the arrangements, including whether they are written
or oral agreements. If written, submit copies of all such agreements.

Yes

Yes
Yes

No
No

Yes

5 a Do you provide for a portion of your services and facilities to be used for charity patients? If “Yes,”
answer 5b through 5e.
b Explain your policy regarding charity cases, including how you distinguish between charity care and bad
debts. Submit a copy of your written policy.
c Provide data on your past experience in admitting charity patients, including amounts you expend for
treating charity care patients and types of services you provide to charity care patients.
d Describe any arrangements you have with federal, state, or local governments or government agencies
for paying for the cost of treating charity care patients. Submit copies of any written agreements.
e Do you provide services on a sliding fee schedule depending on financial ability to pay? If “Yes,” submit
your sliding fee schedule.
6 a Do you or will you carry on a formal program of medical training or medical research? If “Yes,” describe
such programs, including the type of programs offered, the scope of such programs, and affiliations with
other hospitals or medical care providers with which you carry on the medical training or research
programs.

Yes

b Do you or will you carry on a formal program of community education? If “Yes,” describe such programs,
including the type of programs offered, the scope of such programs, and affiliation with other hospitals or
medical care providers with which you offer community education programs.

Yes

Do you or will you provide office space to physicians carrying on their own medical practices? If “Yes,”
describe the criteria for who may use the space, explain the means used to determine that you are paid
at least fair market value, and submit representative lease agreements.
Is your board of directors comprised of a majority of individuals who are representative of the community
you serve? Include a list of each board member’s name and business, financial, or professional
relationship with the hospital. Also, identify each board member who is representative of the community
and describe how that individual is a community representative.

Yes

Do you participate in any joint ventures? If “Yes,” state your ownership percentage in each joint venture,
list your investment in each joint venture, describe the tax status of other participants in each joint
venture (including whether they are section 501(c)(3) organizations), describe the activities of each joint
venture, describe how you exercise control over the activities of each joint venture, and describe how
each joint venture furthers your exempt purposes. Also, submit copies of all agreements.

Yes

Internal Use Only
DRAFT AS OF
November 21, 2013

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

1023

(Rev. 12-2013)

12-2017

Version A, Cycle 4

12-2017
Form 1023 (Rev. 12-2013)

Section I
10

Name:

EIN:

Page

Schedule C. Hospitals and Medical Research Organizations (Continued)
Hospitals (Continued)

Yes

Do you or will you offer recruitment incentives to physicians? If “Yes,” describe your recruitment
incentives and attach copies of all written recruitment incentive policies.
Do you or will you lease equipment, assets, or office space from physicians who have a financial or
professional relationship with you? If “Yes,” explain how you establish a fair market value for the lease.
Have you purchased medical practices, ambulatory surgery centers, or other business assets from
physicians or other persons with whom you have a business relationship, aside from the purchase? If
“Yes,” submit a copy of each purchase and sales contract and describe how you arrived at fair market
value, including copies of appraisals.

Yes

Have you adopted a conflict of interest policy consistent with the sample health care organization
conflict of interest policy in Appendix A of the instructions? If “Yes,” submit a copy of the policy and
explain how the policy has been adopted, such as by resolution of your governing board. If “No,” explain
how you will avoid any conflicts of interest in your business dealings.

Yes

Section II

Internal Use Only
DRAFT AS OF
November 21, 2013
Medical Research Organizations

Name the hospitals with which you have a relationship and describe the relationship. Attach copies of
written agreements with each hospital that demonstrate continuing relationships between you and the
hospital(s).

Attach a schedule describing your present and proposed activities for the direct conduct of medical
research; describe the nature of the activities, and the amount of money that has been or will be spent in
carrying them out.
Attach a schedule of assets showing their fair market value and the portion of your assets directly
devoted to medical research.

Form

1023

(Rev. 12-2013)

12-2017

12-2017
Form 1023 (Rev. 12-2013)

Section I

Version A, Cycle 4
Name:

EIN:

Page

Schedule D. Section 509(a)(3) Supporting Organizations
Identifying Information About the Supported Organization(s)

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

Are all supported organizations listed in line 1 public charities under section 509(a)(1) or (2)? If “Yes,” go
to Section II. If “No,” go to line 3.

Yes

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 supported, provide the following financial information:
• Part IX-A. Statement of Revenues and Expenses, lines 1–13 and
• Part X, lines 6b(ii)(a), 6b(ii)(b), and 7.
If “No,” attach a statement describing how each organization you support is a public charity under
section 509(a)(1) or (2).

Yes

Section II

Relationship with Supported Organization(s)—Three Tests

To be classified as a supporting organization, an organization must meet one of three relationship tests:
Test 1: “Operated, supervised, or controlled by” one or more publicly supported organizations, or
Test 2: “Supervised or controlled in connection with” one or more publicly supported organizations, or
Test 3: “Operated in connection with” one or more publicly supported organizations.
1
Information to establish the “operated, supervised, or controlled by” relationship (Test 1)
Is a majority of your governing board or officers elected or appointed by the supported organization(s)?
If “Yes,” describe the process by which your governing board is appointed and elected; go to Section III.
If “No,” continue to line 2.
2

Internal Use Only
DRAFT AS OF
November 21, 2013

Information to establish the “supervised or controlled in connection with” relationship (Test 2)
Does a majority of your governing board consist of individuals who also serve on the governing board of
the supported organization(s)? If “Yes,” describe the process by which your governing board is appointed
and elected; go to Section III. If “No,” go to line 3.

Yes

b Do one or more members of the governing body of the supported organization(s) also serve as your
officers, directors, or trustees or hold other important offices with respect to you? If “Yes,” explain and
provide documentation; go to line 4d, below. If “No,” go to line 4c.

Yes

c Do your officers, directors, or trustees maintain a close and continuous working relationship with the
officers, directors, or trustees of the supported organization(s)? If “Yes,” explain and provide
documentation.

Yes

d Do the supported organization(s) have a significant voice in your investment policies, in the making and
timing of grants, and in otherwise directing the use of your income or assets? If “Yes,” explain and
provide documentation.
e Describe and provide copies of written communications documenting how you made the supported
organization(s) aware of your supporting activities.

Yes

Information to establish the “operated in connection with” responsiveness test (Test 3)
Are you a trust from which the named supported organization(s) can enforce and compel an accounting
under state law? If “Yes,” explain whether you advised the supported organization(s) in writing of these
rights and provide a copy of the written communication documenting this; go to Section II, line 5. If “No,”
go to line 4a.
Information to establish the alternative “operated in connection with” responsiveness test (Test 3)
a Do the officers, directors, trustees, or members of the supported organization(s) elect or appoint one or
more of your officers, directors, or trustees? If “Yes,” explain and provide documentation; go to line 4d,
below. If “No,” go to line 4b.

Information to establish the “operated in connection with” integral part test (Test 3)
Do you conduct activities that would otherwise be carried out by the supported organization(s)? If “Yes,”
explain and go to Section III. If “No,” continue to line 6a.
Form

1023

(Rev. 12-2013)

12-2017

Version A, Cycle 4

12-2017
Form 1023 (Rev. 12-2013)

Section II
6

Name:

EIN:

Page

Schedule D. Section 509(a)(3) Supporting Organizations (Continued)
Relationship with Supported Organization(s)—Three Tests (Continued)

Information to establish the alternative “operated in connection with” integral part test (Test 3)
a 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 to each supported organization. Also
explain how you ensure that the supported organization(s) are attentive to your operations.

Yes

1 a If you met relationship Test 1 or Test 2 in Section II, your organizing document must specify the
supported organization(s) by name, or by naming a similar purpose or charitable class of beneficiaries. If
your organizing document complies with this requirement, answer “Yes.” If your organizing document
does not comply with this requirement, answer “No,” and see the instructions.

Yes

b If you met relationship Test 3 in Section II, your organizing document must generally specify the
supported organization(s) by name. If your organizing document complies with this requirement, answer
“Yes,” and go to Section IV. If your organizing document does not comply with this requirement, answer
“No,” and see the instructions.

Yes

b How much do you contribute annually to each supported organization? Attach a schedule.
c What is the total annual revenue of each supported organization? If you need additional space, attach a
list.
d Do you or the supported organization(s) earmark your funds for support of a particular program or
activity? If “Yes,” explain.
7 a Does your organizing document specify the supported organization(s) by name? If “Yes,” state the article
and paragraph number and go to Section III. If “No,” answer line 7b.
b Attach a statement describing whether there has been an historic and continuing relationship between
you and the supported organization(s).

Section III

Section IV

Organizational Test

Internal Use Only
DRAFT AS OF
November 21, 2013
Disqualified Person Test

You do not qualify as a supporting organization if you are controlled directly or indirectly by one or more disqualified persons (as
defined in section 4946) other than foundation managers or one or more organizations that you support. Foundation managers who
are also disqualified persons for another reason are disqualified persons with respect to you.
1 a Do any persons who are disqualified persons with respect to you, (except individuals who are
disqualified persons only because they are foundation managers), appoint any of your foundation
managers? If “Yes,” (1) describe the process by which disqualified persons appoint any of your
foundation managers, (2) provide the names of these disqualified persons and the foundation managers
they appoint, and (3) explain how control is vested over your operations (including assets and activities)
by persons other than disqualified persons.

Yes

b Do any persons who have a family or business relationship with any disqualified persons with respect to
you, (except individuals who are disqualified persons only because they are foundation managers),
appoint any of your foundation managers? If “Yes,” (1) describe the process by which individuals with a
family or business relationship with disqualified persons appoint any of your foundation managers,
(2) provide the names of these disqualified persons, the individuals with a family or business relationship
with disqualified persons, and the foundation managers appointed, and (3) explain how control is vested
over your operations (including assets and activities) in individuals other than disqualified persons.

Yes

c Do any persons who are disqualified persons, (except individuals who are disqualified persons only
because they are foundation managers), have any influence regarding your operations, including your
assets or activities? If “Yes,” (1) provide the names of these disqualified persons, (2) explain how
influence is exerted over your operations (including assets and activities), and (3) explain how control is
vested over your operations (including assets and activities) by individuals other than disqualified
persons.

Yes

Form

1023

(Rev. 12-2013)

12-2017

Version A, Cycle 4

12-2017
Form 1023 (Rev. 12-2013)

Name:

EIN:

Page

Schedule E. Organizations Not Filing Form 1023 Within 27 Months of Formation
Schedule E is intended to determine whether you are eligible for tax exemption under section 501(c)(3) from the postmark date of your
application or from your date of incorporation or formation, whichever is earlier. If you are not eligible for tax exemption 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 between your date of incorporation or formation and the postmark date of your
application.
1

Are you a church, association of churches, or integrated auxiliary of a church? If “Yes,” complete
Schedule A and stop here. Do not complete the remainder of Schedule E.

Yes

2 a Are you a public charity with annual gross receipts that are normally $5,000 or less? If “Yes,” stop here.
Answer “No” if you are a private foundation, regardless of your gross receipts.
b If your gross receipts were normally more than $5,000, are you filing this application within 90 days from
the end of the tax year in which your gross receipts were normally more than $5,000? If “Yes,” stop here.

Yes

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

Yes

b If you were included as a subordinate in a group exemption letter, are you filing this application within 27
months from the date you were notified by the organization holding the group exemption letter or the
Internal Revenue Service that you cease to be covered by the group exemption letter? If “Yes,” stop here.

Yes

c If you were included as a subordinate in a timely filed group exemption request that was denied, are you
filing this application within 27 months from the postmark date of the Internal Revenue Service final
adverse ruling letter? If “Yes,” stop here.
4
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
5
formation unless you qualify for an extension of time to apply for exemption. Do you wish to request an
extension of time to apply to be recognized as exempt from the date you were formed? If “Yes,” attach a
statement explaining why you did not file this application within the 27-month period. Do not answer lines
6, 7, or 8. If “No,” go to line 6a.

Yes

6 a If you answered “No” to line 5, you can only be exempt under section 501(c)(3) from the postmark date of
this application. Therefore, do you want us to treat this application as a request for tax exemption from
the postmark date? If “Yes,” you are eligible for an advance ruling. Complete Part X, line 6a. If “No,” you
will be treated as a private foundation.

Yes

Internal Use Only
DRAFT AS OF
November 21, 2013

Note. Be sure your ruling eligibility agrees with your answer to Part X, line 6.
b Do you anticipate significant changes in your sources of support in the future? If “Yes,” complete line 7
below.

Form

1023

(Rev. 12-2013)

12-2017

Version A, Cycle 4
Name:

Form 1023 (Rev. 12-2013)

EIN:

Page

Schedule E. Organizations Not Filing Form 1023 Within 27 Months of Formation (Continued)
Complete this item only if you answered “Yes” to line 6b. Include projected revenue for the first two full years following the
current tax year.
Type of Revenue

Projected revenue for 2 years following current tax year
(a) From
(b) From
(c) Total
To
To

1 Gifts, grants, and contributions received (do not
include unusual grants)
2 Membership fees received
3 Gross investment income
4 Net unrelated business income
5 Taxes levied for your benefit
6 Value of services or facilities furnished by a
governmental unit without charge (not including
the value of services generally furnished to the
public without charge)
7 Any revenue not otherwise listed above or in lines
9–12 below (attach an itemized list)

Internal Use Only
DRAFT AS OF
November 21, 2013

8 Total of lines 1 through 7

9 Gross receipts from admissions, merchandise
sold, or services performed, or furnishing of
facilities in any activity that is related to your
exempt purposes (attach itemized list)
10 Total of lines 8 and 9

11 Net gain or loss on sale of capital assets
(attach an itemized list)
12 Unusual grants

13 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 Form 1023. Tax exemption under section 501(c)(4)
allows exemption from federal income tax, but generally 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 Exemption Under Section
501(a), to this application.
Form

1023

(Rev. 12-2013)

12-2017

Version A, Cycle 4

12-2017
Form 1023 (Rev. 12-2013)

Section I

Name:

EIN:

Page

Schedule F. Homes for the Elderly or Handicapped and Low-Income Housing
General Information About Your Housing

Describe the type of housing you provide.

Provide copies of any application forms you use for admission.

Explain how the public is made aware of your facility.

4a
b
c
d

Provide 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 housing from you.

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

Yes

Note. Make sure your answer is consistent with the information provided in Part VIII, line 8.
7

Do you or will you contract with another organization to develop, build, market, or finance your housing?
If “Yes,” explain how that entity is selected, explain how the terms of any contract(s) are negotiated at
arm’s length, and explain how you determine you will pay no more than fair market value for services.

Internal Use Only
DRAFT AS OF
November 21, 2013

Note. Make sure your answer is consistent with the information provided in Part 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 managed by others, the names of the persons or
organizations that manage or will manage your activities or facilities, and how these managers were or
will be selected. Also, submit copies of any contracts, proposed contracts, or other agreements
regarding the provision of management services for your activities or facilities. Explain how the terms of
any contracts or other agreements were or will be negotiated, and explain how you determine you will
pay no more than fair market value for services.

Note. Answer “Yes” if you do manage or intend to manage your programs through your own employees
or by using volunteers. Answer “No” if you engage or intend to engage a separate organization or
independent contractor. Make sure your answer is consistent with the information provided in Part VIII,
line 7b.
9
Do you participate in any government housing programs? If “Yes,” describe these programs.
10 a Do you own the facility? If “No,” describe any enforceable rights you possess to purchase the facility in
the future; go to line 10c. If “Yes,” answer line 10b.

b How did you acquire the facility? For example, did you develop it yourself, purchase a project, etc.
Attach all contracts, transfer agreements, or other documents connected with the acquisition of the
facility.
c 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.
Form

Yes

Yes
Yes

No
No

Yes

1023

(Rev. 12-2013)

12-2017

Form 1023 (Rev. 12-2013)

Section II

Version A, Cycle 4
Name:

EIN:

Page

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

1 a Do you provide housing for the elderly? If “Yes,” describe who qualifies for your housing in terms of age,
infirmity, or other criteria and explain how you select persons for your housing.
b Do you provide housing for the handicapped? If “Yes,” describe who qualifies for your housing in terms
of disability, income levels, or other criteria and explain how you select persons for your housing.
2 a Do you charge an entrance or founder’s fee? If “Yes,” describe what this charge covers, whether it is a
one-time fee, how the fee is determined, whether it is payable in a lump sum or on an installment basis,
whether it is refundable, and the circumstances, if any, under which it may be waived.
b Do you charge periodic fees or maintenance charges? If “Yes,” describe what these charges cover and
how they are determined.

Yes

c Is your housing affordable to a significant segment of the elderly or handicapped persons in the
community? Identify your community. Also, if “Yes,” explain how you determine your housing is
affordable.
3 a Do you have an established policy concerning residents who become unable to pay their regular
charges? If “Yes,” describe your established policy.
b Do you have any arrangements with government welfare agencies or others to absorb all or part of the
cost of maintaining residents who become unable to pay their regular charges? If “Yes,” describe these
arrangements.

Yes

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

Yes

Are your facilities designed to meet the physical, emotional, recreational, social, religious, and/or other
similar needs of the elderly or handicapped? If “Yes,” describe these design features.

Section III

Internal Use Only
DRAFT AS OF
November 21, 2013

Yes

Low-Income Housing

Do you provide low-income housing? If “Yes,” describe who qualifies for your housing in terms of
income levels or other criteria, and describe how you select persons for your housing.

Yes

In addition to rent or mortgage payments, do residents pay periodic fees or maintenance charges? If
“Yes,” describe what these charges cover and how they are determined.

Yes

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

Yes

Note. Revenue Procedure 96-32, 1996-1 C.B. 717, provides guidelines for providing low-income housing
that will be treated as charitable. (At least 75% of the units are occupied by low-income tenants or 40%
are occupied by tenants earning not more than 120% of the very low-income levels for the area.)
b Do you impose any restrictions to make sure that your housing remains affordable to low-income
residents? If “Yes,” describe these restrictions.
4

Do you provide social services to residents? If “Yes,” describe these services.
Form

1023

(Rev. 12-2013)

12-2017

12-2017
Form 1023 (Rev. 12-2013)

Version A, Cycle 4
Name:

EIN:

Page

Schedule G. Successors to Other Organizations

1 a Are you a successor to a for-profit organization? If “Yes,” explain the relationship with the
predecessor organization that resulted in your creation and complete line 1b.
b Explain why you took over the activities or assets of a for-profit organization or converted from for-profit
to nonprofit status.

Yes

2 a Are you a successor to an organization other than a for-profit organization? Answer “Yes” if you have
taken or will take over the activities of another organization; or you have taken or will take over 25% or
more of the fair market value of the net assets of another organization. If “Yes,” explain the relationship
with the other organization that resulted in your creation.

Yes

b Provide the tax status of the predecessor organization.
c Did you or did an organization to which you are a successor previously apply for tax exemption under
section 501(c)(3) or any other section of the Code? If “Yes,” explain how the application was resolved.
d 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.
e Explain why you took over the activities or assets of another organization.
3
Provide the name, last address, and EIN of the predecessor organization and describe its activities.
Name:
EIN:
Address:
4

List the owners, partners, principal stockholders, officers, and governing board members of the predecessor organization.
Attach a separate sheet if additional space is needed.
Name

Address

Share/Interest (If a for-profit)

Internal Use Only
DRAFT AS OF
November 21, 2013

Do or will any of the persons listed in line 4, maintain a working relationship with you? If “Yes,” describe
the relationship in detail and include copies of any agreements with any of these persons or with any
for-profit organizations in which these persons own more than a 35% interest.

Yes

6 a Were any assets transferred, whether by gift or sale, from the predecessor organization to you? If “Yes,”
provide a list of assets, indicate the value of each asset, explain how the value was determined, and
attach an appraisal, if available. For each asset listed, also explain if the transfer was by gift, sale, or
combination thereof.

Yes

b Were any restrictions placed on the use or sale of the assets? If “Yes,” explain the restrictions.
c Provide a copy of the agreement(s) of sale or transfer.
7
Were any debts or liabilities transferred from the predecessor for-profit organization to you?
If “Yes,” provide a list of the debts or liabilities that were transferred to you, indicating the amount of
each, how the amount was determined, and the name of the person to whom the debt or liability is
owed.
8

Will you lease or rent any property or equipment previously owned or used by the predecessor for-profit
organization, or from persons listed in line 4, or from for-profit organizations in which these persons own
more than a 35% interest? If “Yes,” submit a copy of the lease or rental agreement(s). Indicate how the
lease or rental value of the property or equipment was determined.

Yes

Will you lease or rent property or equipment to persons listed in line 4, or to for-profit organizations in
which these persons own more than a 35% interest? If “Yes,” attach a list of the property or equipment,
provide a copy of the lease or rental agreement(s), and indicate how the lease or rental value of the
property or equipment was determined.

Yes

Form

1023

(Rev. 12-2013)

12-2017

Version A, Cycle 4

Page 25
Schedule H. Organizations Providing Scholarships, Fellowships, Educational Loans, or Other Educational Grants
to Individuals and Private Foundations Requesting Advance Approval of Individual Grant Procedures
Section I
Names of individual recipients are not required to be listed in Schedule H.
Public charities and private foundations complete lines 1a through 7 of this section. See the
instructions to Part X if you are not sure whether you are a public charity or a private foundation.
Form 1023 (Rev. 12-2013)

Name:

EIN:

1 a Describe the types of educational grants you provide to individuals, such as scholarships, fellowships, loans, etc.
b Describe the purpose and amount of your scholarships, fellowships, and other educational grants and loans that
you award.
c
d
e
f
2

If you award educational loans, explain the terms of the loans (interest 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, trustees, or donors of funds to you? If “No,” refer
to the instructions.

Yes

Describe the specific criteria you use to determine who is eligible for your program. (For example, eligibility
selection criteria could consist of graduating high school students from a particular high school who will attend
college, writers of scholarly works about American history, etc.)
4 a Describe the specific criteria you use to select recipients. (For example, specific selection criteria could consist of
prior academic performance, financial need, etc.)
b Describe how you determine the number of grants that will be made annually.
c Describe how you determine the amount of each of your grants.
d Describe any requirement or condition that you impose on recipients to obtain, maintain, or qualify for renewal of a
grant. (For example, specific requirements or conditions could consist of attendance at a four-year college,
maintaining a certain grade point average, teaching in public school after graduation from college, etc.)
Describe your procedures for supervising the scholarships, fellowships, educational loans, or other educational
5
grants. Describe whether you obtain reports and grade transcripts from recipients, or you pay grants directly to a
school under an arrangement whereby the school will apply the grant funds only for enrolled students who are in
good standing. Also, describe your procedures for taking action if the terms of the award are violated.

Internal Use Only
DRAFT AS OF
November 21, 2013

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 measures are taken to ensure
unbiased selections?

Yes

Note. If you are a private foundation, you are not permitted to provide educational grants to disqualified
persons. Disqualified persons include your substantial contributors and foundation managers and
certain family members of disqualified persons.

Section II

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

1 a If we determine that you are a private foundation, do you want this application to be
considered as a request for advance approval of grant making procedures?

Yes

N/A

b For which section(s) do you wish to be considered?
• 4945(g)(1)—Scholarship or fellowship grant to an individual for study at an educational institution
• 4945(g)(3)—Other grants, including loans, to an individual for travel, study, or other similar
purposes, to enhance a particular skill of the grantee or to produce a specific product
2

Do you represent that you will (1) arrange to receive and review grantee reports annually and
upon completion of the purpose for which the grant was awarded, (2) investigate diversions of
funds from their intended purposes, and (3) take all reasonable and appropriate steps to
recover diverted funds, ensure other grant funds held by a grantee are used for their intended
purposes, and withhold further payments to grantees until you obtain grantees’ assurances
that future diversions will not occur and that grantees will take extraordinary precautions to
prevent future diversions from occurring?

Yes

Do you represent that you will maintain all records relating to individual grants, including
information obtained to evaluate grantees, identify whether a grantee is a disqualified person,
establish the amount and purpose of each grant, and establish that you undertook the
supervision and investigation of grants described in line 2?

Yes

Form

1023

(Rev. 12-2013)

12-2017

Version A, Cycle 4

Page 26
Schedule H. Organizations Providing Scholarships, Fellowships, Educational Loans, or Other Educational Grants
to Individuals and Private Foundations Requesting Advance Approval of Individual Grant Procedures (Continued)
Section II
Private foundations complete lines 1a through 4f of this section. Public charities do not complete
this section. (Continued)
Form 1023 (Rev. 12-2013)

Name:

EIN:

4 a Do you or will you award scholarships, fellowships, and educational loans to attend an
educational institution based on the status of an individual being an employee of a particular
employer? If “Yes,” complete lines 4b through 4f.

Yes

b Will you comply with the seven conditions and either the percentage tests or facts and
circumstances test for scholarships, fellowships, and educational loans to attend an
educational institution as set forth in Revenue Procedures 76-47, 1976-2 C.B. 670, and 80-39,
1980-2 C.B. 772, which apply to inducement, selection committee, eligibility requirements,
objective basis of selection, employment, course of study, and other objectives? (See lines 4c,
4d, and 4e, regarding the percentage tests.)

Yes

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

Yes

If “Yes,” will you award grants to 10% or fewer of the eligible applicants who were actually
considered by the selection committee in selecting recipients of grants in that year as provided
by Revenue Procedures 76-47 and 80-39?
d Do you provide scholarships, fellowships, or educational loans to attend an educational
institution to children of employees of a particular employer?

Yes

If “Yes,” will you award grants to 25% or fewer of the eligible applicants who were actually
considered by the selection committee in selecting recipients of grants in that year as provided
by Revenue Procedures 76-47 and 80-39? If “No,” go to line 4e.

Yes

e If you provide scholarships, fellowships, or educational loans to attend an educational
institution to children of employees of a particular employer, will you award grants to 10% or
fewer of the number of employees’ children who can be shown to be eligible for grants
(whether or not they submitted an application) in that year, as provided by Revenue
Procedures 76-47 and 80-39?

Yes

Internal Use Only
DRAFT AS OF
November 21, 2013

N/A

If “Yes,” describe how you will determine who can be shown to be eligible for grants without
submitting an application, such as by obtaining written statements or other information about
the expectations of employees’ children to attend an educational institution. If “No,” go to line
4f.
Note. Statistical or sampling techniques are not acceptable. See Revenue Procedure
85-51, 1985-2 C.B. 717, for additional information.
f

If you provide scholarships, fellowships, or educational loans to attend an educational
institution to children of employees of a particular employer without regard to either the 25%
limitation described in line 4d, or the 10% limitation described in line 4e, will you award grants
based on facts and circumstances that demonstrate that the grants will not be considered
compensation for past, present, or future services or otherwise provide a significant benefit to
the particular employer? If “Yes,” describe the facts and circumstances that you believe will
demonstrate that the grants are neither compensatory nor a significant benefit to the particular
employer. In your explanation, describe why you cannot satisfy either the 25% test described
in line 4d or the 10% test described in line 4e.

Form

1023

(Rev. 12-2013)

12-2017

Version A, Cycle 4

Form 1023 Checklist

2017

(Revised December 2013)
Application for Recognition of Exemption under Section 501(c)(3) of the
Internal Revenue Code
Note. Retain a copy of the completed Form 1023 in your permanent records. Refer to the General Instructions regarding
Public Inspection of approved applications.
Check each box to finish your application (Form 1023). Send this completed Checklist with your filled-in
application. If you have not answered all the items below, your application may be returned to you as
incomplete.
Assemble the application and materials in this order:
• Form 1023 Checklist
• Form 2848, Power of Attorney and Declaration of Representative (if filing)
• Form 8821, Tax Information Authorization (if filing)
• Expedite request (if requesting)
• Application (Form 1023 and Schedules A through H, as required)
• Articles of organization
• Amendments to articles of organization in chronological order
• Bylaws or other rules of operation and amendments
• Documentation of nondiscriminatory policy for schools, as required by Schedule B
• Form 5768, Election/Revocation of Election by an Eligible Section 501(c)(3) Organization To Make
Expenditures To Influence Legislation (if filing)
• All other attachments, including explanations, financial data, and printed materials or publications.
Label each page with name and EIN.

Internal Use Only
DRAFT AS OF
November 21, 2013

User fee payment placed in envelope on top of checklist. DO NOT STAPLE or otherwise attach your
check or money order to your application. Instead, just place it in the envelope.
Employer Identification Number (EIN)

Completed Parts I through XI of the application, including any requested information and any
required Schedules A through H.
• You must provide specific details about your past, present, and planned activities.
• Generalizations or failure to answer questions in the Form 1023 application will prevent us from
recognizing you as tax exempt.
• Describe your purposes and proposed activities in specific easily understood terms.
• Financial information should correspond with proposed activities.
Schedules. Submit only those schedules that apply to you and check either “Yes” or “No” below.
Schedule A

Yes

Schedule E

Yes

Schedule B

Yes

Schedule F

Yes

Schedule C

Yes

Schedule G

Yes

Schedule D

Yes

Schedule H

Yes

Version A, Cycle 4

An exact copy of your complete articles of organization (creating document). Absence of the proper purpose
and dissolution clauses is the number one reason for delays in the issuance of determination letters.
• Location of Purpose Clause from Part III, line 1 (Page, Article and Paragraph Number)
• Location of Dissolution Clause from Part III, line 2b or 2c (Page, Article and Paragraph Number) or by
operation of state law
Signature of an officer, director, trustee, or other official who is authorized to sign the application.
• Signature at Part XI of Form 1023.
Your name on the application must be the same as your legal name as it appears in your articles of
organization.
Send completed Form 1023, user fee payment, and all other required information, to:

Internal Revenue Service
Attention: EO Determination Letter
Stop 31

Internal Revenue Service
P.O. Box 192
Covington, KY 41012-0192

P.O.Box 12192
Covington, KY 41012-0192
RP 2017-5, Section 15.01(2)

If you are using express mail or a delivery service, send Form 1023, user fee payment, and attachments to:
Internal Revenue Service
201 West Rivercenter Blvd.
Attn: Extracting Stop 312
Covington, KY 41011

Internal Revenue Service
Attention: EO
Determination Letters

Internal Use Only
DRAFT AS OF
November 21, 2013
Stop 13

201 West Rivercenter Boulevard
Covington, KY 41011

RP 2017-5, Section 15.03

File Type	application/pdf
File Title	Form 1023 (Rev. December 2013)
Subject	Fillable
Author	SE:W:CAR:MP
File Modified	2017-04-21
File Created	2006-06-22