Fillable Form 1023

What is Form 1023?

Form 1023 is a crucial document utilized by organizations seeking recognition as tax-exempt entities under section 501(c)(3) of the Internal Revenue Code (IRC). This form is filed with the Internal Revenue Service (IRS) in the United States and serves as the initial step in the process of obtaining tax-exempt status. The completion of Form 1023 is mandatory for organizations wishing to qualify for federal income tax exemption as charitable, religious, educational, scientific, literary, testing for public safety, fostering national or international amateur sports competition, or preventing cruelty to children or animals organizations.

Some organizations, such as churches, charities, and other similar organizations, are considered tax-exempt, and are not subject to taxes like most other organizations are. This can be for a variety of reasons, depending on the type of organization and state laws, but the IRS provides recognition of exemption to organizations that file Form 1023 and fully qualify for all of the requirements set by them, from bank account and earnings organization to the nature and frequency of their work.

While exempt organizations will not have to pay tax, they do still have to report their mailing addresses (and any changes to them) to the IRS in order to ensure that they receive important correspondence from the IRS, even if it is not for tax-paying purposes.

How do I fill out Form 1023?

You may find a fillable copy of Form 1023 here. Make sure to keep track of all of the schedules you fill out as part of this form, and to double-check all information you enter so as to avoid having to file everything again in the event of an error. Doing so will also help to avoid issues with your federal income tax exemption, and give you an easy and stress-free tax exempt application process.

If more space is needed in order to provide an explanation or description as requested by Form 1023 or one of the Schedule forms, label it appropriately and attach it to this form.

Part I - Identification of Applicant

Lines 1 to 6c

Enter the following identification information for the applicant in the corresponding spaces provided.

1. Full name of organization
2. c/o Name (if applicable)
3. Mailing Address
   1. Number and Street Address
   2. Room/Suite
   3. City or town, state or country, and ZIP + 4
4. Employer Identification Number (EIN)
5. Month the annual accounting period ends (01-12)
6. Primary Contact
   1. Name
   2. Phone number
   3. Fax number

As well, enter your name and EIN in the spaces provided at the top of each page of this form.

Line 7

Check “Yes” if you are represented by an authorized representative, then provide your representative’s name, and the name and address of their firm. Include a completed Form 2848 with your application as well, if you wish to provide a line of communication with your representative. Otherwise, check “No”.

Line 8

If a person who is not one of your officers, directors, trustees, employees, or representatives has paid or promised payment to help you plan and/or manage the structure or activities of your organization, or about your financial tax matters, check “Yes” and provide that person’s name, the name and address of that person’s firm, the amounts paid or promised to be paid, and describe that person’s role. Otherwise check “No”.

Line 9a and 9b

Enter your organization’s website and email address.

Line 10

If you are granted tax-exemption and are claiming to be excused from filing Form 990 or 990-EZ, check “Yes” and attach a description to this form. Otherwise check “No”.

Line 11

Enter the date your corporation or other organization was incorporated or formed.

Line 12

If your organization was formed under the laws of a foreign country, check “Yes” and enter what country. Otherwise check “No”.

Part II - Organizational Structure

Answer “Yes” or “No” to each of the following questions.

1. Are you a corporation?
   1. If Yes - attach a copy of your articles of incorporation showing certification of filing with the appropriate state agency.
2. Are you a Limited Liability Company (LLC)?
   1. If Yes - attach a copy of your articles of organization showing certification of filing with the appropriate state agency, as well as a copy of an operating agreement if you adopted one.
3. Are you an unincorporated association?
   1. If Yes - attach a copy of your articles of association, constitution, or other similar organizing document.
4. Are you a trust?
   1. If Yes - attach a signed and dated copy of your trust agreement, as well as signed and dated copies of any amendments made to the original.
   2. If No - attach a short explanation of how you are formed without anything of value placed in trust.
5. Have you adopted bylaws?
   1. If Yes - attach a current copy showing date of adoption.
   2. If No - explain how your other officers, directors, or trustees are selected.

Part III - Required Provisions in Your Organizing Document

Make sure that you fit the provisions outlined in this section and can mark the boxes provided. Then provide the following information in the spaces provided.

1. Location of Purpose Clause
2. Remaining Assets use after dissolution
   1. Check the box provided if you fit the provisions outlined in this line.
   2. If box 2a was checked, specify the location of your dissolution clause.
   3. If you rely on operation of state law for your dissolution provision, check the box and indicate the state.

Part IV - Narrative Description of Your Activities

This section outlines how narratives are defined and used with regards to the filing of this form.

Part V - Compensation and Other Financial Arrangements with your Officers, Directors, Trustees, Employees, and Independent Contractors

Line 1a

Enter the following information for all of your officers, directors, and trustees in the relevant columns in the table provided below. Attach a separate sheet if more space is needed.

• Name
• Title
• Mailing Address
• Compensation Amount

Line 1b

Enter the following information for each of your five highest compensated employees who receive or will receive compensation of more than $50,000 per year. Do not include officers, directors, or trustees already listed in 1a.

• Name
• Title
• Mailing Address
• Compensation Amount

Line 1c

Enter the following information for each of your five highest independent contractors who receive or will receive compensation of more than $50,000 per year.

• Name
• Title
• Mailing Address
• Compensation Amount

Lines 2a to 2b

Answer “Yes” or “No” to the following questions.

• 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.
• 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 and describe the business relationship with each of your officers, directors, or trustees.
• 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.

Line 3a and 3b

Take note of each of the following.

• 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.
• 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 agreement.

Line 4a to 4g

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 of the below that you practice.

• Follow a conflict of interest policy
• Approve compensation arrangements in advance of paying compensation
• Document in writing the date and terms of approved compensation arrangements
• Record in writing the decision made by each individual who decided or voted on compensation arrangements
• 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
• Record in writing both the information on which you relied to base your decision and its source
• If you answered “no” to any of the above, describe how you set reasonable compensation for your officers, directors, trustees, highest compensated employees, and highest compensated independent contractors listed in Part V, Lines 1a, 1b, and 1c.

Line 5a to 5c

Answer the following questions.

• 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.
  • If No - Answer Lines 5b and 5c.
• 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?
• 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?

Line 6a and 6b

Answer the questions below.

• 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.
• 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.

Line 7a and 7b

Answer the questions below.

• 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. Also attach copies of any written contracts or other agreements relating to such purchases.
• Do you or will you sell any goods, services, or assets to any of your 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. Also attach copies of any written contracts or other agreements relating to such sales.

Line 8a to 8f

Provide the information requested below.

• 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.
• 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.

Line 9a to 9f

Provide the information requested below.

• 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.
• Describe any written or oral arrangements you made or intend to make. c 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 - 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

1. Exempt Purposes
   1. 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.
   2. 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.
2. Do any of your programs limit the provision of goods, services, or funds to a specific individual or group of specific individuals? If “Yes,” explain the limitation and how recipients are selected for each program.
3. 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.

Part VII - Your History

Answer the following “Yes” or “No” questions as relating to your history.

1. Are you a successor to another organization? 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 - Your Specific Activities

Part VIII Your Specific Activities The following “Yes” or “No” questions relate to specific activities that you may conduct. These answers should pertain to all activities past, present, and planned.

1. Do you support or oppose candidates in political campaigns in any way? If “Yes,” explain.
2. Political Activity
   1. Do you attempt to influence legislation? If “Yes,” explain how you attempt to influence legislation and complete line 2b. If “No,” go to line 3a.
   2. 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.
3. Gaming
   1. 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.
   2. 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
   3. List the states and local jurisdictions, including Indian Reservations, in which you conduct or will conduct gaming or bingo.
4. Do you or will you undertake fundraising?
   1. If “Yes,” check all the fundraising programs you do or will conduct from the following. Attach a description of each fundraising program.
      1. Mail solicitations
      2. Phone solicitations
      3. Email solicitations
      4. Accept donations on your website
      5. Personal solicitations
      6. Receive donations from another organization's website
      7. Vehicle, boat, plane, or similar donations
      8. Government grant solicitations
      9. Foundation grant solicitations
      10. Other (specify)
   2. 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.
   3. Do you or will you engage in fundraising activities for other organizations? If “Yes,” describe these arrangements.
   4. 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.
   5. 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? If “Yes,” describe this program, including the type of advice that may be provided and submit copies of any written materials provided to donors.
5. Are you affiliated with a governmental unit? If “Yes,” explain.
6. Economic Development
   1. Do you or will you engage in economic development? If “Yes,” describe your program.
   2. Describe in full who benefits from your economic development activities and how the activities promote exempt purposes.
7. Development and Management
   1. 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.
   2. 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.
   3. 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. 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. Childcare
   1. 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.
   2. Do you provide childcare 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).
   3. Of the children for whom you provide childcare, 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).
   4. Are your services available to the general public? If “No,” describe the specific group of people for whom your activities are available.
10. 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.
11. 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.
12. Operation in Foreign Countries
    1. 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.
    2. Name the foreign countries and regions within the countries in which you operate.
    3. Describe your operations in each country and region in which you operate.
    4. Describe how your operations in each country and region further your exempt purposes.
13. Grants, Loans, or other Distributions
    1. 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.
    2. Describe how your grants, loans, or other distributions to organizations further your exempt purposes.
    3. Do you have written contracts with each of these organizations? If “Yes,” attach a copy of each contract.
    4. Identify each recipient organization and any relationship between you and the recipient organization.
    5. Describe the records you keep with respect to the grants, loans, or other distributions you make.
    6. Describe your selection process, including whether you do any of the following.
       1. Do you require an application form? If “Yes,” attach a copy of the form.
       2. 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.
    7. Describe your procedures for oversight of distributions that assure you the resources are used to further your exempt purposes.
14. Grants, Loans, or other Distributions to Foreign Organizations
    1. 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.
    2. 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.
    3. 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.
    4. 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.
    5. Do you or will you make pre-grant inquiries about the recipient organization? If “Yes,” describe these inquiries.
    6. 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.
15. Do you have a close connection with any organizations? If “Yes,” explain.
16. Are you applying for exemption as a cooperative hospital service organization under section 501(e)? If “Yes,” explain.
17. Are you applying for exemption as a cooperative service organization of operating educational organizations under section 501(f)? If “Yes,” explain.
18. Are you applying for exemption as a charitable risk pool under section 501(n)? If “Yes,” explain.
19. Do you or will you operate a school? If “Yes,” complete Schedule B.
20. Is your main function to provide hospital or medical care?
21. Do you or will you provide low-income housing or housing for the elderly or handicapped? If “Yes,” complete Schedule F.
22. 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.

Part IX - Financial Data

Section A - Statement of Revenues and Expenses

For each of the types of revenue or expense in the table provided, enter the following information per column:

• Current Tax Year (Enter the starting year and the ending year).
• 3 prior tax years or 2 succeeding tax years.
• Provide Total for the amounts entered for all of the above.

Section B - Balance Sheet (for your most recently completed tax year)

Enter the year end value in whole dollars for each of the following.

Assets

1. Cash
2. Accounts receivable, net
3. Inventories
4. Bonds and notes receivable (attach an itemized list)
5. Corporate stocks (attach an itemized list)
6. Loans receivable (attach an itemized list)
7. Other investments (attach an itemized list)
8. Depreciable and depletable assets (attach an itemized list)
9. Land
10. Other assets (attach an itemized list)
11. Total Assets (enter the sum of Lines 1 through 10)

Liabilities

12. Accounts payable
13. Contributions, gifts, grants, etc. payable
14. Mortgages and notes payable (attach an itemized list)
15. Other liabilities (attach an itemized list)
16. Total liabilities (enter the sum of Lines 12 through 15)

Fund Balances or Net Assets

17. Total fund balances or net assets
18. Total liabilities and fund balances or net assets ( add Lines 16 and 17).
19. Have there been any substantial changes in your assets or liabilities since the end of the period shown above. If “Yes”, explain.

Part X - Public Charity Status

This section is designed to classify you as an organization that is either a private foundation or a public charity.

Answer the questions below and provide the requested information.

1. Private Foundation
   1. Are you a private foundation? If “Yes,” go to line 1b. If “No,” go to line 5 and proceed as instructed.
   2. 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.
2. Are you a private operating foundation? If “Yes,” go to line 3. If “No,” go to the signature section of Part XI.
3. 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.
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?
5. Private foundation (check the box that corresponds to the type of public charity status you are requesting).
   1. 509(a)(1) and 170(b)(1)(A)(i)—a church or a convention or association of churches. Complete and attach Schedule A
   2. 509(a)(1) and 170(b)(1)(A)(ii)—a school. Complete and attach Schedule B
   3. 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.
   4. 509(a)(3)—an organization supporting either one or more organizations described in line 5a through c, f, h, or i or a publicly supported section 501(c)(4), (5), or (6) organization. Complete and attach Schedule D.
   5. 509(a)(4) – an organization organized and operated exclusively for testing for public safety.
   6. 509(a)(1) and 170(b)(1)(A)(iv) – an organization operated for the benefit of a college or university that is owned or operated by a governmental unit.
   7. 509(a)(1) and 170(b)(1)(A)(ix) – an agricultural research organization directly engaged in the continuous active conduct of agricultural research in conjunction with a college or university.
   8. 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 supported organizations, from a governmental unit, or from the general public.
   9. 509(a)(2) – an organization that normally receives not more than one-third of its financial support from gross investment income and receives more than one-third of its financial support from contributions, membership fees, and gross receipts from activities related to its exempt functions (subject to certain exceptions).
   10. A publicly supported organization, but unsure if it is described in 5h or 5i. You would like the IRS to decide the correct status.
6. If you checked box h, i, or j in question 5 above, and you have been in existence more than 5 years, you must confirm your public support status. Answer line 6a if you checked box h in line 5 above. Answer line 6b if you checked box i in line 5 above. If you checked box j in line 5 above, answer both lines 6a and 6b.
   1. Contributions
      1. Enter 2% of line 8, column (e) on Part IX-A Statement of Revenues and Expenses
      2. 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,” state this.
   2. Contributions from disqualified persons
      1. 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 and amount received from each disqualified person. If the answer is “None,” state this.
      2. 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, 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.

Part XI - User Fee Information and Signature

Amount of the User Fee paid

Enter the amount you have included with this application as payment for the user fee.

Signature

Have yourself or the officer, director, trustee, or other authorized official filing this form sign it in the space provided. Then enter the name of the person who signed the form, their title within your organization, and the date that the form was signed.

Schedule A - Churches

Answer the following questions and enter the requested information when necessary.

1. Summary of beliefs/Form of worship
   1. Do you have a written creed, statement of faith, or summary of beliefs? If “Yes,” attach copies of relevant documents.
   2. Do you have a form of worship? If “Yes,” describe your form of worship.
2. Code, History, and Literature
   1. Do you have a formal code of doctrine and discipline? If “Yes,” describe your code of doctrine and discipline.
   2. Do you have a distinct religious history? If “Yes,” describe your religious history.
   3. Do you have a literature of your own? If “Yes,” describe your literature.
3. Describe the organization’s religious hierarchy or ecclesiastical government.
4. Religious Services
   1. 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.
   2. What is the average attendance at your regularly scheduled religious services?
5. Place of Worship
   1. Do you have an established place of worship? If “Yes,” refer to the instructions for the information required.
   2. Do you own the property where you have an established place of worship?
6. Do you have an established congregation or other regular membership group? If “No,” refer to the instructions.
7. How many members do you have?
8. Membership
   1. Do you have a process by which an individual becomes a member? If “Yes,” describe the process and complete lines 8b–8d, below.
   2. 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.
   3. May your members be associated with another denomination or church?
   4. Are all of your members part of the same family?
9. Do you conduct baptisms, weddings, funerals, etc.?
10. Do you have a school for the religious instruction of the young?
11. Religious Leader
    1. 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.
    2. Do you have schools for the preparation of your ordained ministers or religious leaders?
12. Is your minister or religious leader also one of your officers, directors, or trustees?
13. Do you ordain, commission, or license ministers or religious leaders? If “Yes,” describe the requirements for ordination, commission, or licensure.
14. Are you part of a group of churches with similar beliefs and structures? If “Yes,” explain. Include the name of the group of churches.
15. Do you issue church charters? If “Yes,” describe the requirements for issuing a charter.
16. Did you pay a fee for a church charter? If “Yes,” attach a copy of the charter.
17. Do you have other information you believe should be considered regarding your status as a church? If “Yes,” explain.

Schedule B - School, Colleges, and Universities

Section I - Operational Information

Answer the following questions.

1. Curriculum
   1. 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.
   2. 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.
2. Public School
   1. 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
   2. 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.
3. In what public school district, county, and state are you located?
4. Were you formed or substantially expanded at the time of public school desegregation in the above school district or county?
5. Has a state or federal administrative agency or judicial body ever determined that you are racially discriminatory? If “Yes,” explain.
6. Has your right to receive financial aid or assistance from a governmental agency ever been revoked or suspended? If “Yes,” explain.
7. 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.
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.

Section II - Establishment of Racially Nondiscriminatory Policy

Answer the following questions.

1. 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.
2. Do your brochures, application forms, advertisements, and catalogues dealing with student admissions, programs, and scholarships contain a statement of your racially nondiscriminatory policy?
   1. If Yes - attach a representative sample of each document
   2. 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.
3. 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.
4. 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.
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. Enter the following information in the corresponding columns, and enter the total of each column in the bottom row of the table.:
   1. Racial Category
   2. Student Body
   3. Faculty
   4. Administrative Stuff
6. In the table below, provide the number and amount of loans and scholarships awarded to students enrolled by racial categories, then enter the total of each column in the bottom row of the table:
   1. Racial Category
   2. Number of Loans
   3. Amount of Loans
   4. Number of Scholarships
   5. Amount of Scholarships
7. Incorporators, Founders, Board Members
   1. Attach a list of your incorporators, founders, board members, and donors of land or buildings, whether individuals or organizations.
   2. Do any of these individuals or organizations have an objective to maintain segregated public or private school education? If “Yes,” explain.
8. Will you maintain records according to the nondiscrimination provisions contained in Revenue Procedure 75-50? If “No,” explain. See instructions.

Schedule C - Hospitals and Medical Research Organizations

Section 1 - Hospitals

Answer all of the questions below.

1. 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. Medical Services
   1. 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.
   2. Do you or will you provide medical services to all individuals in your community who participate in Medicare? If “No,” explain.
   3. Do you or will you provide medical services to all individuals in your community who participate in Medicaid? If “No,” explain.
3. Medicare or Medicaid Coverage
   1. Do you or will you require persons covered by Medicare or Medicaid to pay a deposit before receiving services? If “Yes,” explain.
   2. Does the same deposit requirement, if any, apply to all other patients? If “No,” explain.
4. Emergency Room
   1. Do you or will you maintain a full-time emergency room? If “No,” explain why you do not maintain a full-time emergency room.
   2. Do you have a policy on providing emergency services to persons without apparent means to pay? If “Yes,” provide a copy of the policy.
   3. 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.
5. Charity Cases
   1. Do you provide for a portion of your services and facilities to be used for charity patients? If “Yes,” answer 5b through 5e
   2. Explain your policy regarding charity cases, including how you distinguish between charity care and bad debts. Submit a copy of your written policy.
   3. 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.
   4. 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.
   5. Do you provide services on a sliding fee schedule depending on financial ability to pay? If “Yes,” submit your sliding fee schedule.
6. Medical Training
   1. Do you or will you carry on a formal program of medical training or medical research? If “Yes,” describe such programs.
   2. Do you or will you carry on a formal program of community education? If “Yes,” describe such programs.
7. 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.
8. 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.
9. 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.
10. 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.
11. 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.
12. 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
13. 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.
14. 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.

Section II - Medical Research Organizations

Enter the requested information for each line below.

1. 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).
2. 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.
3. Attach a schedule of assets showing their fair market value and the portion of your assets directly devoted to medical research.

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

Section I - Identifying Information About the Supported Organization(s)

Enter the information requested and answer the questions in the lines below.

1. Information about supported organizations.
   1. Name
   2. Address
   3. EIN
2. 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.
3. Do the supported organizations have tax-exempt status under section 501(c)(4), 501(c)(5), or 501(c)(6)?
   1. If Yes - for each 501(c)(4), (5), or (6) organization supported, provide the following financial information.
      1. Part IX-A. Statement of Revenues and Expenses, lines 1–13, and
      2. Part X, lines 6b(i), 6b(ii), and 7
   2. If No - attach a statement describing how each organization you support is a public charity under section 509(a)(1) or (2).

Section II - Relationship with Supported Organization(s)—Three Tests

Note that 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
• Test 2: “Supervised or controlled in connection with” one or more publicly supported organizations
• Test 3: “Operated in connection with” one or more publicly supported organizations.

Answer each of the “Yes” or “No” questions in the lines below.

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)?
   1. If Yes - describe the process by which your governing board is appointed and elected; go to Section III.
   2. If No - continue to Line 2.
2. Information to establish the “supervised or controlled in connection with” relationship (Test 2) Does a majority of your governing board consist of individuals who also serve on the governing board of the supported organization(s)?
   1. If Yes - describe the process by which your governing board is appointed and elected; go to Section III.
   2. If No - go to Line 3.
3. 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?
   1. 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.
   2. If No - go to Line 4a.
4. Information to establish the alternative “operated in connection with” responsiveness test (Test 3)
   1. Do the officers, directors, trustees, or members of the supported organization(s) elect or appoint one or more of your officers, directors, or trustees?
      1. If “Yes,” explain and provide documentation; go to line 4d, below.
      2. If “No,” go to line 4b.
   2. 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?
      1. If “Yes,” explain and provide documentation; go to line 4d, below.
      2. If “No,” go to line 4c.
   3. Do your officers, directors, or trustees maintain a close and continuous working relationship with the officers, directors, or trustees of the supported organization(s)?
      1. If “Yes,” explain and provide documentation.
   4. 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?
      1. If “Yes,” explain and provide documentation.
   5. Describe and provide copies of written communications documenting how you made the supported organization(s) aware of your supporting activities.
5. 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)?
   1. If Yes - If “Yes,” explain and go to Section III.
   2. If No - continue to Line 6a.
6. Information to establish the alternative “operated in connection with” integral part test (Test 3)
   1. Do you distribute at least 85% of your annual net income to the supported organization(s)?
      1. If “Yes,” go to line 6b.
      2. 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.
   2. How much do you contribute annually to each supported organization?
   3. What is the total annual revenue of each supported organization?
   4. Do you or the supported organization(s) earmark your funds for support of a particular program or activity?
      1. If “Yes”, explain.
7. Organizing Document
   1. Does your organizing document specify the supported organization(s) by name?
      1. If “Yes,” state the article and paragraph number and go to Section III.
      2. If “No,” answer line 7b.
   2. Attach a statement describing whether there has been an historic and continuing relationship between you and the supported organization(s).

Section III - Organizational Test

Answer the two questions below.

1. Organizational Test
   1. 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.
      1. If your organizing document complies with this requirement, answer “Yes.”
      2. If your organizing document does not comply with this requirement, answer “No,” and see the instructions.
   2. If you met relationship Test 3 in Section II, your organizing document must generally specify the supported organization(s) by name.
      1. If your organizing document complies with this requirement, answer “Yes,” and go to Section IV.
      2. If your organizing document does not comply with this requirement, answer “No,” and see the instructions.

Section IV - Disqualified Person Test

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, you do not qualify as a supporting organization. Answer the questions below.

1. Disqualified Person Test
   1. 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?
      1. 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.
   2. 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?
      1. 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.
   3. 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?
      1. 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.

Schedule E - Organizations Not Filing Form 1023 Within 27 Months of Formation

This schedule 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.

Answer the questions as listed below.

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.
2. Public Charity
   1. 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.
   2. 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.
3. Subordinate
   1. Were you included as a subordinate in a group exemption application or letter? If “No,” go to line 4.
   2. 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.
   3. 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.
5. If you answered “No” to lines 1 through 4, we cannot recognize you as tax exempt from your date of formation unless you qualify for an extension of time to apply for 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 or 7. If “No,” go to line 6a.
6. Eligibility
   1. 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 this application to be treated as a request for tax exemption from the postmark date?
   2. Do you anticipate significant changes in your sources of support in the future? If “Yes,” complete line 7 below.
7. Projected Revenue. Enter the amount of projected revenue for two years following the current tax year for each type of revenue in the table below. (Complete this item only if you answered “Yes” to line 6b.)

Schedule F - Homes for the Elderly or Handicapped and Low-Income Housing

Section I - General Information About Your Housing

Provide the requested details and answer the questions below.

1. Describe the type of housing you provide.
2. Provide copies of any application forms you use for admission
3. Explain how the public is made aware of your facility.
4. Facility Information
   1. Provide a description of each facility.
   2. What is the total number of residents each facility can accommodate?
   3. What is your current number of residents in each facility?
   4. Describe each facility in terms of whether residents rent or purchase housing from you.
5. Attach a sample copy of your residency or homeownership contract or agreement.
6. Do you participate in any joint ventures?
   1. 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.
7. Do you or will you contract with another organization to develop, build, market, or finance your housing?
   1. 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.
8. Do you or will you manage your activities or facilities through your own employees or volunteers?
   1. 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.
9. Do you participate in any government housing programs?
   1. If “Yes,” describe these programs.
10. Facility Ownership
    1. Do you own the facility? If “No,” describe any enforceable rights you possess to purchase the facility in the future; go to line 10c.
       1. If “Yes,” answer line 10b.
    2. How did you acquire the facility?
    3. Do you lease the facility or the land on which it is located?
       1. If “Yes,” describe the parties to the lease(s) and provide copies of all leases.

Section II - Homes for the Elderly or Handicapped

Answer the questions below.

1. Housing for the Elderly and/or Handicapped
   1. Do you provide housing for the elderly?
      1. 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.
   2. Do you provide housing for the handicapped?
      1. 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. Entrance/Founder’s Fee
   1. Do you charge an entrance or founder’s fee?
      1. 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.
   2. Do you charge periodic fees or maintenance charges?
      1. If “Yes,” describe what these charges cover and how they are determined.
   3. Is your housing affordable to a significant segment of the elderly or handicapped persons in the community?
      1. Identify your community
      2. Also, if “Yes,” explain how you determine your housing is affordable.
3. Policy for Those Unable To Pay
   1. Do you have an established policy concerning residents who become unable to pay their regular charges?
      1. If “Yes,” describe your established policy
   2. 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?
      1. If “Yes,” describe these arrangements.
4. Do you have arrangements for the healthcare needs of your residents?
   1. If “Yes,” describe these arrangements.
5. Are your facilities designed to meet the physical, emotional, recreational, social, religious, and/or other similar needs of the elderly or handicapped?
   1. If “Yes,” describe these design features.

Section III - Low-income Housing

Answer the questions in each of the lines below.

1. Do you provide low-income housing?
   1. 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.
2. In addition to rent or mortgage payments, do residents pay periodic fees or maintenance charges?
   1. If “Yes,” describe what these charges cover and how they are determined.
3. Affordability
   1. Is your housing affordable to low income residents?
      1. If “Yes,” describe how your housing is made affordable to low-income residents.
   2. Do you impose any restrictions to make sure that your housing remains affordable to low-income residents?
      1. If “Yes,” describe these restrictions.
   3. Do you provide social services to residents?
      1. If “Yes,” describe these services.

Schedule G - Successors to Other Organizations

Answer each of the questions below.

1. Successor to non-profit
   1. Are you a successor to a for-profit organization?
      1. If “Yes,” explain the relationship with the predecessor organization that resulted in your creation and complete line 1b.
   2. Explain why you took over the activities or assets of a for-profit organization or converted from for-profit to nonprofit status.
2. Successor to any other organization besides a non-profit
   1. Are you a successor to an organization other than a for-profit organization?
      1. If “Yes,” explain the relationship with the other organization that resulted in your creation.
   2. Provide the tax status of the predecessor organization.
   3. 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?
      1. If “Yes,” explain how the application was resolved.
   4. 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?
      1. If “Yes,” explain how the application was resolved.
   5. 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 provide a short description of its activities.
4. Enter the following information for each owner, partner, principal officer or stockholder, officer, and governing board members of the predecessor organization. Attach an additional sheet of paper if more space is needed.
   1. Name
   2. Address
   3. Share/Interest
5. Do or will any of the persons listed in line 4, maintain a working relationship with you?
   1. 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.
6. Asset Transfers
   1. Were any assets transferred, whether by gift or sale, from the predecessor organization to you?
      1. 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.
   2. Were any restrictions placed on the use or sale of the assets?
      1. If “Yes,” explain the restrictions.
   3. 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?
   1. 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?
   1. 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.
9. 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?
   1. 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.

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

Note that names of individual recipients are not required to be listed in Schedule H. As well, 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.

1. Educational Grants
   1. Describe the types of educational grants you provide to individuals, such as scholarships, fellowships, loans, etc.
   2. Describe the purpose and amount of your scholarships, fellowships, and other educational grants and loans that you award.
   3. If you award educational loans, explain the terms of the loans (interest rate, length, forgiveness, etc.).
   4. Specify how your program is publicized.
   5. Provide copies of any solicitation or announcement materials.
   6. Provide a sample copy of the application used.
2. 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?
   1. If “No,” refer to the instructions.
3. Describe the specific criteria you use to determine who is eligible for your program.
4. Criteria to select recipients
   1. Describe the specific criteria you use to select recipients.
   2. Describe how you determine the number of grants that will be made annually.
   3. Describe how you determine the amount of each of your grants.
   4. Describe any requirement or condition that you impose on recipients to obtain, maintain, or qualify for renewal of a grant.
5. Describe your procedures for supervising the scholarships, fellowships, educational loans, or other educational 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.
6. 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?
7. Are relatives of members of the selection committee, or of your officers, directors, or substantial contributors eligible for awards made under your program?
   1. If “Yes,” what measures are taken to ensure unbiased selections?

Section II

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

1. Request for advance approval
   1. 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?
   2. For which section(s) do you wish to be considered?
      1. 4945(g)(1)—Scholarship or fellowship grant to an individual for study at an educational institution
      2. 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?
3. 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?
4. Scholarship Awarding Criteria
   1. 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?
      1. If “Yes,” complete lines 4b through 4f.
   2. 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?
   3. Do you or will you provide scholarships, fellowships, or educational loans to attend an educational institution to employees of a particular employer?
      1. 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?
   4. Do you provide scholarships, fellowships, or educational loans to attend an educational institution to children of employees of a particular employer?
      1. 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?
      2. If “No,” go to line 4e.
   5. 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?
      1. 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.
      2. If “No,” go to line 4f.
   6. 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?
      1. 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.

Frequently Asked Questions (FAQs)

Is there a filing fee for Form 1023?

Yes, there is a filing fee associated with Form 1023, which varies depending on the organization's gross receipts.

How long does it take to process Form 1023?

Processing times vary, but it can take several months for the IRS to review and approve Form 1023.

What happens if Form 1023 is not filed?

Failure to file Form 1023 may result in the organization being subject to income tax on its earnings.

Can Form 1023 be filed electronically?

No, Form 1023 must be filed by mail with the appropriate IRS office.

Can an organization operate while its Form 1023 is pending?

Yes, an organization can operate while its Form 1023 is pending, but it may not receive tax-exempt status until the application is approved.

Are there any restrictions on the activities of organizations filing Form 1023?

Yes, organizations filing Form 1023 must adhere to certain restrictions on political activity, lobbying, and private benefit.

What is a determination letter?

A determination letter is a document issued by the IRS confirming an organization's tax-exempt status after approval of Form 1023.