Form 1023 is filed electronically only on Pay.gov.

Go to www.irs.gov/form1023 for additional filing information.

Form 1023

(Rev. December 2017)

Department of the Treasury

Internal Revenue Service

Application for Recognition of Exemption

Under Section 501(c)(3) of the Internal Revenue Code

▶Do not enter social security numbers on this form as it may be made public. ▶ Go to www.irs.gov/Form1023 for instructions and the latest information.

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
1	Full name of organization (exactly as it appears in your organizing document)			2	c/o Name (if applicable)

3	Mailing address (Number and street) (see instructions)		Room/Suite	4	Employer Identification Number (EIN)

	City or town, state or country, and ZIP + 4			5	Month the annual accounting period ends (01 – 12)

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

				c	Fax: (optional)

7Are 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

8Was 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

9a Organization’s website:

bOrganization’s email: (optional)

10Certain 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.

Yes

11	Date incorporated if a corporation, or formed, if other than a corporation.		(MM/DD/YYYY)	/	/
12	Were you formed under the laws of a foreign country?				Yes	No
	If “Yes,” state the country.

For Paperwork Reduction Act Notice, see instructions.		Cat. No. 17133K			Form 1023 (Rev. 12-2017)

Form 1023 (Rev. 12-2017)

Name:

EIN:

Page 2

Part II 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	Yes	No
		filing with the appropriate state agency. Include copies of any amendments to your articles and be sure
		they also show state filing certification.

2		Are you a limited liability company (LLC)? If “Yes,” attach a copy of your articles of organization showing	Yes	No
		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.

3		Are you an unincorporated association? If “Yes,” attach a copy of your articles of association,	Yes	No
		constitution, or other similar organizing document that is dated and includes at least two signatures.
		Include signed and dated copies of any amendments.

	4a	Are you a trust? If “Yes,” attach a signed and dated copy of your trust agreement. Include signed and	Yes	No
		dated copies of any amendments.
	b	Have you been funded? If “No,” explain how you are formed without anything of value placed in trust.	Yes	No
	5	Have you adopted bylaws? If “Yes,” attach a current copy showing date of adoption. If “No,” explain	Yes	No
		how your officers, directors, or trustees are selected.

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.

1Section 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.

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.

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

1a 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.

Name

Title

Mailing address

Compensation amount (annual actual or estimated)

Form 1023 (Rev. 12-2017)


Form 1023 (Rev. 12-2017)		Name:	EIN:	Page 3
Part V	Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees, Employees,
	and Independent Contractors (Continued)

bList 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

Mailing address

Compensation amount (annual actual or estimated)

cList 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

Mailing address

Compensation amount (annual actual or estimated)

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.

2a	Are any of your officers, directors, or trustees related to each other through family or business	Yes	No
	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	Yes	No
	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	Yes	No
	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	Yes	No
	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.

4In 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?	Yes	No
b	Do you or will you approve compensation arrangements in advance of paying compensation?	Yes	No
c	Do you or will you document in writing the date and terms of approved compensation arrangements?	Yes	No

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

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

eDo 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	No
Yes	No

f Do you or will you record in writing both the information on which you relied to base your decision and its	Yes	No
source?

gIf 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.

5a Have you adopted a conflict of interest policy consistent with the sample conflict of interest policy in	Yes	No
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.

bWhat 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?

cWhat 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.

6a	Do you or will you compensate any of your officers, directors, trustees, highest compensated employees, and highest	Yes	No
	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.
b	Do you or will you compensate any of your employees, other than your officers, directors, trustees, or your	Yes	No
	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.

7a	Do you or will you purchase any goods, services, or assets from any of your officers, directors, trustees, highest	Yes	No
	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.
b	Do you or will you sell any goods, services, or assets to any of your officers, directors, trustees, highest	Yes	No
	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.

8a	Do you or will you have any leases, contracts, loans, or other agreements with your officers, directors,	Yes	No
	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.

bDescribe any written or oral arrangements that you made or intend to make.

cIdentify with whom you have or will have such arrangements.

dExplain how the terms are or will be negotiated at arm’s length.

eExplain how you determine you pay no more than fair market value or you are paid at least fair market value. f Attach copies of any signed leases, contracts, loans, or other agreements relating to such arrangements.

9a Do you or will you have any leases, contracts, loans, or other agreements with any organization in which

Yes

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. 12-2017)


Form 1023 (Rev. 12-2017)		Name:	EIN:	Page 5
Part V	Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees,
	Employees, and Independent Contractors (Continued)

bDescribe any written or oral arrangements you made or intend to make.

cIdentify with whom you have or will have such arrangements.

dExplain how the terms are or will be negotiated at arm’s length.

eExplain how you determine or will determine you pay no more than fair market value or that you are paid at least fair market value.

fAttach 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. 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.

bIn 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	No
Yes	No


2	Do any of your programs limit the provision of goods, services, or funds to a specific individual or group		Yes	No
	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.

3	Do any individuals who receive goods, services, or funds through your programs have a family or		Yes	No
	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

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		Yes	No
		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
		nonprofit 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		Yes	No
		legally formed? If “Yes,” complete Schedule E.

	Part VIII		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.
b	Have you made or are you making an election to have your legislative activities measured by	Yes	No
	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.

3a 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.

bDo 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.

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

Yes	No
Yes	No

Form 1023 (Rev. 12-2017)

Form 1023 (Rev. 12-2017)		Name:	EIN:		Page 6
Part VIII	Your Specific Activities (Continued)
4 a Do	you or will you undertake fundraising? If “Yes,” check all the fundraising programs you do or will			Yes	No
conduct. See instructions.
	mail solicitations		phone solicitations
	email solicitations		accept donations on your website
	personal solicitations		receive donations from another organization’s website
	vehicle, boat, plane, or similar donations		government grant solicitations
	foundation 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	Yes	No
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.
c Do you or will you engage in fundraising activities for other organizations? If “Yes,” describe these	Yes	No
arrangements. Include a description of the organizations for which you raise funds and attach copies of
all contracts or agreements.

dList 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	Yes	No
	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.

5	Are you affiliated with a governmental unit? If “Yes,” explain.	Yes	No
6a	Do you or will you engage in economic development? If “Yes,” describe your program.	Yes	No

bDescribe in full who benefits from your economic development activities and how the activities promote exempt purposes.

7a	Do or will persons other than your employees or volunteers develop your facilities? If “Yes,” describe	Yes	No
	each facility, the role of the developer, and any business or family relationship(s) between the developer
	and your officers, directors, or trustees.
b	Do or will persons other than your employees or volunteers manage your activities or facilities? If “Yes,”	Yes	No
	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.

cIf 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	Yes	No
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.

9a 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.

bDo 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).

Yes	No
Yes	No

cOf 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).

dAre 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	No
Yes	No

10 Do you or will you publish, own, or have rights in music, literature, tapes, artworks, choreography,

Yes

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.

Form 1023 (Rev. 12-2017)


Form 1023 (Rev. 12-2017)			Name:	EIN:		Page 7
Part VIII		Your Specific Activities (Continued)
11	Do you or will you accept contributions of: real property; conservation easements; closely held				Yes	No
	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 a	Do you or will you operate in a foreign country or countries? If “Yes,” answer lines 12b through 12d. If				Yes	No
	“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.

13a	Do you or will you make grants, loans, or other distributions to organization(s)? If “Yes,” answer lines 13b				Yes	No
	through 13g. If “No,” go to line 14a.

bDescribe how your grants, loans, or other distributions to organizations further your exempt purposes.

c Do you have written contracts with each of these organizations? If “Yes,” attach a copy of each contract.

Yes

dIdentify each recipient organization and any relationship between you and the recipient organization.

eDescribe the records you keep with respect to the grants, loans, or other distributions you make.

fDescribe 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.	Yes	No
(ii)	Do you require a grant proposal? If “Yes,” describe whether the grant proposal specifies your	Yes	No
	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.

gDescribe 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.

bProvide 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.

cDoes 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.

dDo 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.

eDo 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.

fDo 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	No
Yes	No
Yes	No
Yes	No
Yes	No

Form 1023 (Rev. 12-2017)


	Form 1023 (Rev. 12-2017)			Name:	EIN:		Page 8
	Part VIII		Your Specific Activities (Continued)
15		Do you have a close connection with any organizations? If “Yes,” explain.				Yes	No
	16	Are you applying for exemption as a cooperative hospital service organization under section 501(e)? If				Yes	No
		“Yes,” explain.

	17	Are you applying for exemption as a cooperative service organization of operating educational				Yes	No
		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.				Yes	No
	19	Do you or will you operate a school? If “Yes,” complete Schedule B. Answer “Yes,” whether you operate				Yes	No
		a school as your main function or as a secondary activity.

	20	Is your main function to provide hospital or medical care? If “Yes,” complete Schedule C.				Yes	No
	21	Do you or will you provide low-income housing or housing for the elderly or handicapped? If “Yes,”				Yes	No
		complete Schedule F.

	22	Do you or will you provide scholarships, fellowships, educational loans, or other educational grants to				Yes	No
		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.

Form 1023 (Rev. 12-2017)


Form 1023 (Rev. 12-2017)		Name:	EIN:	Page 9
Part IX	Financial Data

For purposes of this schedule, years in existence refer to completed tax years.

1.If in existence less than 5 years, complete the statement for each year in existence and provide projections of your likely revenues and expenses based on a reasonable and good faith estimate of your future finances for a total of:

a.Three years of financial information if you have not completed one tax year, or

b.Four years of financial information if you have completed one tax year. See instructions.

2.If in existence 5 or more years, complete the schedule for the most recent 5 tax years. You will need to provide a separate statement that includes information about the most recent 5 tax years because the data table in Part IX has not been updated to provide for a 5th year. See instructions.

A.Statement of Revenues and Expenses

Revenues

Expenses

Type of revenue or expense	Current tax year		3 prior tax years or 2 succeeding tax years

	(a) From	(b) From	(c) From	(d) From	(e) Provide Total for
	To	To	To	To	(a) through (d)

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

2Membership fees received

3Gross investment income

4Net unrelated business income

5Taxes levied for your benefit

6Value of services or facilities furnished by a governmental unit without charge (not including the value of services generally furnished to the public without charge)

7Any revenue not otherwise listed above or in lines 9–12 below (attach an itemized list)

8Total of lines 1 through 7

9Gross 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)

10Total of lines 8 and 9

11Net gain or loss on sale of capital assets (attach schedule and see instructions)

12Unusual grants

13Total Revenue

Add lines 10 through 12

14 Fundraising expenses

15Contributions, gifts, grants, and similar amounts paid out (attach an itemized list)

16Disbursements to or for the benefit of members (attach an itemized list)

17Compensation 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

23Any expense not otherwise classified, such as program services (attach itemized list)

24Total Expenses

Add lines 14 through 23

Form 1023 (Rev. 12-2017)

	Form 1023 (Rev. 12-2017)			Name:	EIN:			Page 10
	Part IX		Financial Data (Continued)
				B. Balance Sheet (for your most recently completed tax year)			Year End:
				Assets			(Whole dollars)
1		Cash				1
2		Accounts receivable, net				2
3		Inventories				3
4		Bonds and notes receivable (attach an itemized list)				4
5		Corporate stocks (attach an itemized list)				5
6		Loans receivable (attach an itemized list)				6
7		Other investments (attach an itemized list)				7
8		Depreciable and depletable assets (attach an itemized list)				8
9		Land				9
10		Other assets (attach an itemized list)				10
11		Total Assets (add lines 1 through 10)				11
				Liabilities
12		Accounts payable				12
13		Contributions, gifts, grants, etc. payable				13
14		Mortgages and notes payable (attach an itemized list)				14
15		Other liabilities (attach an itemized list)				15
16		Total Liabilities (add lines 12 through 15)				16
				Fund Balances or Net Assets
17		Total fund balances or net assets				17
18		Total Liabilities and Fund Balances or Net Assets (add lines 16 and 17)				18
	19	Have there been any substantial changes in your assets or liabilities since the end of the period					Yes	No
		shown above? If “Yes,” explain.

Part X 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	Yes	No
		are unsure, see the instructions.
	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	Yes	No
		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.

3		Have you existed for one or more years? If “Yes,” attach financial information showing that you are a	Yes	No
		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	Yes	No
		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?

5If 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.

c509(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, h, or i or a publicly supported section 501(c)(4), (5), or (6) organization. Complete and attach Schedule D.

Form 1023 (Rev. 12-2017)