Application Exemption – Fill Out and Use This PDF

CALIFORNIA FORM

Exemption Application

3500

Organization Information

California corporation number/California Secretary of State file number

FEIN

Name of organization as shown in the organization’s creating document

Web address

Street address (suite, room, or PMB no.)

City

State

ZIP code

Telephone

Second telephone

Fax

Representative Information

Name of representative

Email address

Street address (suite, room, or PMB no.)

City

State

ZIP code

Telephone

Second telephone

Fax

General Questions

Part I

Organizational Structure

1

.Is this a foreign corporation?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.□. .Yes. . 1

□No

See General Information F, Foreign Corporations .

2

Is this a trust?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

□Yes

□No

See General Information H, Trusts .

3

Is this a limited liability company (LLC)?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.□. Yes. . .

□. .No

See General Information I, Limited Liability Companies .

DATE

SIGNATURE OF OFFICER OR REPRESENTATIVE

TITLE

Organization name: __________________________

Corp number/CA SOS file number:

Part II Narrative of Activities

1

Was the organization’s California tax-exempt status previously revoked?

. . . . . . . . . . . . . . . . . . . . .

. . . . . . .

. . □. Yes. .

.

.□. No. . . . . 1

If “No,” the organization may qualify to file form FTB 3500A, Submission of Exemption Request . For more information, get form FTB 3500A .

2

Enter the California Revenue and Taxation Code (R&TC) section that best fits the organization’s purpose/activity

See the Exempt Classification Chart on page 6

. . . . . . . . . . . . . . . . . . . . .

. . R&TC. . . . Section. . . . 23701. . . .

. . 2

3

Enter the date the organization formed

. . . . . . . . . . . . . . . . . . . . .

. . . . . ./ .

. .

. / . .

. . . . . . 3

mm /

dd

/

yyyy

6

Is the organization currently conducting, or plan to conduct activities?

. 6. .

□. .Yes. . . □. No

If “Yes,” enter the date the activities began, or will begin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . /.

. .

. ./

mm /

dd

/

yyyy

Organization name: __________________________

Corp number/CA SOS file number:

Organization name: __________________________

Corp number/CA SOS file number:

and prior years?

1a □Yes

□No

b Has the organization filed the FTB 199N, California e-Postcard, for the current and prior years?

. . . □1bYes

□No

a Share any facilities with the organization?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. a.

. □. Yes. .

. .□. No

b Rent, sell, or transfer property to this organization?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

b

□Yes

□No

c Be compensated for services other than performing as a board member or employee?

.

c

□Yes

□No

Part V

History

. . . . .

1 Has the organization been issued any previous California ID number?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. .□. Yes. .

. □. .No.

2

Was this organization’s exemption previously revoked by the Internal Revenue Service?

. □. .Yes. .

. □. No. . 2

If “Yes,” enter date revoked

mm

/

dd

/

yyyy

Part VI

Fund Raising

1

Does or will the organization participate in fund-raising activities? . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . .

.

.

. .□. .Yes. □. 1No. .

If “Yes,” check all the fund-raising programs the organization conducts, or will conduct .

□ Mail solicitations

□ Phone solicitations

□ Email solicitations

□ Accept donations on the organization’s website

□ Personal solicitations

□ Receive donations from another organization’s website

□ Vehicle, boat, plane, or similar donations

□ Government grant solicitations

□ Foundation grant solicitations

□ Other - Attach description

Organization name: __________________________

Corp number/CA SOS file number:

Part VII Specific Activities

1

Does the organization conduct any gaming activities (bingo, raffles, etc .) .

. . . . . . . . . . . . . . . . . . . . . . .

. . .

. . . . . . . . .

.

. .

.

. .

.

1 □Yes □No

2

Does the organization lease property from others?

. . . . . . . . . . . . . . . . . .

. .

. . . . .

. . .

.

.

.

.

. .

. . .□. Yes. . . .

□. . No. 2

If “Yes,” attach copy of lease agreement .

3

Does the organization lease property to others?

. . . . . . . . . . . . . . . . . . . . . . .

.

.

.

.

.

.

. . □. Yes. . .

.□. No

If “Yes,” attach copy of lease agreement .

4

Does or will the organization publish, sell, or distribute any literature? . . .

. . . . . . . . . . . . . . . . . . . . . .

. . .

. . . . . .

. . .

.

. .

.

. .

.

.

4 □Yes

□No

5

Does or will the organization own, or have rights in music, literature, tapes, artworks, choreography, scientific discoveries,

. . □. Yes. . .

.□. No

or other intellectual property?

. . . . . . . . . . . . . . . . . . . . . . .

.

.

.

.

.

.

Organization name: __________________________

Corp number/CA SOS file number:

2

Is the organization formed as a cooperative?

If “Yes,” provide a copy of the federal exemption letter showing exemption under IRC Section 501(c)(5)

2 □Yes □No

the lodge system?

. . . . . 2

□Yes

□No

3

Is the organization a subordinate of a national or state level organization?

. . . . 3.

. □. .Yes. .

. □. No

If “Yes,” attach a certificate signed by the secretary of the parent organization certifying that the subordinate is a duly

constituted body operating under the jurisdiction of the parent body.

4

Is the organization a parent or grand lodge?

. . . . . 4

□Yes

□No

a lodge system?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. .

.□. .Yes. . .

□No

3

Is the organization a subordinate of a national or state level organization?

. . . . . . . . . . . . . . . . . . . . . . . . . . . 3.

. □. .Yes. . . □. No

4

Is the organization a parent or grand lodge?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

□Yes

□No

Organization name: __________________________

Corp number/CA SOS file number:

□ Charitable

□ Educational

□ Credit Counseling

□ Synagogue

□ School

□ Testing for public safety

□ Church

□ Literary

□ Hospital, Medical Center

□ Temple

□ Scientific

□ Qualified sports organization

□ Mosque

□ Religious

□ Prevent cruelty to children or animals

group (brother or sister whether whole or half blood, spouse/RDP, ancestor or lineal descendant)?

2

□Yes

□No

3

Does the organization attempt to influence legislation?

3. . .

□. Yes. . . .

□. . No

voting power of stock in any corporation?

. 5. .

.□. .Yes.

□No

6

a

Does the organization operate as a church, mosque, synagogue, or temple?

.6a. .

.□. .Yes

□No

If “Yes,” complete Schedule 2A, Churches .

b

Is the organization’s main function to provide hospital or medical care?

6b

□Yes

□No

If “Yes,” complete Schedule 2B, Hospitals .

c

Is the organization a credit counseling organization?

6c

□Yes

□No

If “Yes,” complete Schedule 2C, Credit Counseling Organizations .

Organization name: __________________________

Corp number/CA SOS file number:

□Church □Mosque □Synagogue

□Temple

2

Has a place of worship been established?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □. Yes. . . .□. No

If “Yes,” at what address? Who is the legal owner of the property? Other property use?

If “No,” explain where religious services are held .

6

Will any founder, member, or officer take a vow of poverty? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .□. Yes. . . □. .No

If “Yes,” explain .

Organization name: __________________________

Corp number/CA SOS file number:

insurance, etc .)?

8 □Yes □No

If “Yes,” explain .

9

Does the organization have a written creed, statement of faith, or summary of beliefs?

9 □Yes □No

If “Yes,” explain .

10

Do the religious leaders conduct baptisms, weddings, funerals, etc .?

10. . . .□Yes □No

If “Yes,” explain .

11

Does the organization ordain, commission, or license ministers or religious leaders?

11 □Yes □No

If “Yes,” describe .

Organization name: __________________________

Corp number/CA SOS file number:

1

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

1 □Yes □No

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

services?

3a

□Yes

□No

If “Yes,” explain .

b Does the same deposit requirement, if any, apply to all other patients?

3b

□Yes

□No

If “No,” explain .

4

a

Does or will the organization maintain a full-time emergency room?

4a

□Yes

□No

If “No,” explain why the organization does not maintain a full-time emergency room . Also, describe any emergency

services provided .

b

Does the organization have a policy on providing emergency services to persons without apparent means to pay? . . . .

4b. .

□Yes

□No

If “Yes,” provide a copy of the policy.

or admission of emergency cases?

. . .

.□. Yes. . 4c □No

If “Yes,” describe the arrangements, including whether they are written or oral agreements . If written, submit copies of

all such agreements .

5

a

Does the organization provide for a portion of the organization’s services and facilities to be used for charity patients? . . .

5a

□Yes

□No

If “Yes,” answer question 5b through question 5e .

b

Explain the organization’s policy regarding charity cases, including how the organization distinguishes between charity

care and bad debts . Submit a copy of the written policy.

c

Provide data on the organization’s past experience in admitting charity patients, including the amounts expended for

treating charity care patients and types of services provided to charity care patients .

d

Describe any arrangements 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

Does the organization provide services on a sliding fee schedule depending on financial ability to pay?

5e

□Yes

□No

If “Yes,” submit the sliding fee schedule .

6

a

Does or will the organization carry on a formal program of medical training or medical research?

6a

□Yes

□No

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 the organization carries on the medical training or research

programs .

b

Does or will the organization carry on a formal program of community education?

. . .

.□. Yes6b

□No

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 the organization offers community education programs .