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The form you are looking for begins on the next page of this file. Before viewing it, 
please see the important update information below.

                           New Mailing Address

The mailing address for certain forms have change since the forms were last published. 
The new mailing address are shown below. 

Mailing Address for Forms 1023, 1024, 1024-A, 1028, 5300, 5307, 5310, 5310-A, 5316, 
8717, 8718, 8940:

Internal Revenue Service   
TE/GE Stop 31A Team 105                              
P.O. Box 12192       
Covington, KY 41012–0192

Deliveries by private delivery service (PDS) should be made to:

Internal Revenue Service 
7940 Kentucky Drive 
TE/GE Stop 31A Team 105 
Florence, KY 41042

This update supplements these forms’ instructions. Filers should rely on this update for 
the change described, which will be incorporated into the next revision of the form’s 
instructions.

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Application for Recognition of Exemption OMB No. 1545-0056
Form 1023 Under Section 501(c)(3) of the Internal Revenue Code Note: If exempt status is
approved, this
(Rev. December 2017) ▶ Do not enter social security numbers on this form as it may be made public. application will be open
Department of the Treasury
Internal Revenue Service ▶ Go to www.irs.gov/Form1023 for instructions and the latest information. 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, theapplication 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)
7 Are you represented by an authorized representative, such as an attorney or accountant? If “Yes,” Yes No
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.

8 Was a person who is not one of your officers, directors, trustees, employees, or an authorized Yes No
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.
9a Organization’s website:

b Organization’s email: (optional)
10 Certain organizations are not required to file an information return (Form 990 or Form 990-EZ). If you Yes No
are granted tax-exemption, are you claiming to be excused from filing Form 990 or Form 990-EZ? If
“Yes,” explain. See the instructions for a description of organizations not required to file Form 990 or
Form 990-EZ.
11 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)

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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.
1 Section 501(c)(3) requires that your organizing document state your exempt purpose(s), such as charitable,
religious, educational, and/or scientific purposes. Check the box to confirm that your organizing document meets
this requirement. Describe specifically where your organizing document meets this requirement, such as a reference
to a particular article or section in your organizing document. Refer to the instructions for exempt purpose language.
Location of Purpose Clause (Page, Article, and Paragraph):
2 a Section 501(c)(3) requires that upon dissolution of your organization, your remaining assets must be used exclusively
for exempt purposes, such as charitable, religious, educational, and/or scientific purposes. Check the box on line 2a to
confirm that your organizing document meets this requirement by express provision for the distribution of assets upon
dissolution. If you rely on state law for your dissolution provision, do not check the box on line 2a and go to line 2c.
b If you checked the box on line 2a, specify the location of your dissolution clause (Page, Article, and Paragraph).
Do not complete line 2c if you checked box 2a.
c See the instructions for information about the operation of state law in your particular state. Check this box if you
rely on operation of state law for your dissolution provision and indicate the state:
Part IV Narrative Description of Your Activities
Using an attachment, describe your past, present, and planned activities in a narrative. If you believe that you have already provided some of
this information in response to other parts of this application, you may summarize that information here and refer to the specific parts of the
application for supporting details. You may also attach representative copies of newsletters, brochures, or similar documents for supporting
details to this narrative. Remember that if this application is approved, it will be open for public inspection. Therefore, your narrative
description of activities should be thorough and accurate. Refer to the instructions for information that must be included in your description.
Part V 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.
Compensation amount
Name Title Mailing address (annual actual or estimated)

Form 1023 (Rev. 12-2017)

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

c List the names, names of businesses, and mailing addresses of your five highest compensated independent contractors that
receive or will receive compensation of more than $50,000 per year. Use the actual figure, if available. Refer to the instructions
for information on what to include as compensation.
Compensation amount
Name Title Mailing address (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.
4 In establishing the compensation for your officers, directors, trustees, highest compensated employees,
and highest compensated independent contractors listed on lines 1a, 1b, and 1c, the following practices
are recommended, although they are not required to obtain exemption. Answer “Yes” to all the practices
you use.
a Do you or will the individuals that approve compensation arrangements follow a conflict of interest policy? 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

Form 1023 (Rev. 12-2017)

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Form 1023 (Rev. 12-2017) Name: EIN: Page 4
Part V Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees, Employees,
and Independent Contractors (Continued)
d Do you or will you record in writing the decision made by each individual who decided or voted on Yes No
compensation arrangements?
e Do you or will you approve compensation arrangements based on information about compensation paid by Yes No
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.
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?
g If you answered “No” to any item on lines 4a through 4f, describe how you set compensation that is
reasonable for your officers, directors, trustees, highest compensated employees, and highest
compensated independent contractors listed in Part V, lines 1a, 1b, and 1c.
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.
b What procedures will you follow to assure that persons who have a conflict of interest will not have
influence over you for setting their own compensation?
c What procedures will you follow to assure that persons who have a conflict of interest will not have
influence over you regarding business deals with themselves?
Note: A conflict of interest policy is recommended though it is not required to obtain exemption.
Hospitals, see Schedule C, Section I, line 14.
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 non-fixedpaymentsthrough , 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 arm’sat length, and explain how you determine or will determine that you pay no
more thanfair marketvalue . 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.
b Describe any written or oral arrangements that you made or intend to make.
c Identify with whom you have or will have such arrangements.
d Explain how the terms are or will be negotiated at arm’s length.
e Explain 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 No
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)

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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)
b Describe any written or oral arrangements you made or intend to make.
c Identify with whom you have or will have such arrangements.
d Explain how the terms are or will be negotiated at arm’s length.
e 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.
f 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. See instructions.
1 a In carrying out your exempt purposes, do you provide goods, services, or funds to individuals? If “Yes,” Yes No
describe each program that provides goods, services, or funds to individuals.
b In carrying out your exempt purposes, do you provide goods, services, or funds to organizations? If Yes No
“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 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 Yes No
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.
b Do you or will you enter into contracts or other agreements with individuals or organizations to conduct Yes No
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.
c List the states and local jurisdictions, including Indian Reservations, in which you conduct or will conduct
gaming or bingo.
Form 1023 (Rev. 12-2017)

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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.
d List all states and local jurisdictions in which you conduct fundraising. For each state or local jurisdiction
listed, specify whether you fundraise for your own organization, you fundraise for another organization, or
another organization fundraises for you.
e Do you or will you maintain separate accounts for any contributor under which the contributor has the 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
b Describe 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.
c If there is a business or family relationship between any manager or developer and your officers,
directors, or trustees, identify the individuals, explain the relationship, describe how contracts are
negotiated at arm’s length so that you pay no more than fair market value, and submit a copy of any
contracts or other agreements.
8 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 Yes No
9b through 9d. If “No,” go to line 10.
b Do you provide childcare so that parents or caretakers of children you care for can be gainfully Yes No
employed (see instructions)? If “No,” explain how you qualify as a childcare organization described in
section 501(k).
c Of the children for whom you provide childcare, are 85% or more of them cared for by you to enable their Yes No
parents or caretakers to be gainfully employed (see instructions)? If “No,” explain how you qualify as a
childcare organization described in section 501(k).
d Are your services available to the general public? If “No,” describe the specific group of people for whom Yes No
your activities are available. Also, see the instructions and explain how you qualify as a childcare
organization described in section 501(k).
10 Do you or will you publish, own, or have rights in music, literature, tapes, artworks, choreography, Yes No
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)

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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.
b Describe 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 No
d Identify each recipient organization and any relationship between you and the recipient organization.
e Describe the records you keep with respect to the grants, loans, or other distributions you make.
f Describe your selection process, including whether you do any of the following.
(i) Do you require an application form? If “Yes,” attach a copy of the form. 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.
g Describe your procedures for oversight of distributions that assure you the resources are used to further
your exempt purposes, including whether you require periodic and final reports on the use of resources.
14 a Do you or will you make grants, loans, or other distributions to foreign organizations? If “Yes,” answer Yes No
lines 14b through 14f. If “No,” go to line 15.
b Provide the name of each foreign organization, the country and regions within a country in which each
foreign organization operates, and describe any relationship you have with each foreign organization.
c Does any foreign organization listed in line 14b accept contributions earmarked for a specific country or Yes No
specific organization? If “Yes,” list all earmarked organizations or countries.
d Do your contributors know that you have ultimate authority to use contributions made to you at your Yes No
discretion for purposes consistent with your exempt purposes? If “Yes,” describe how you relay this
information to contributors.
e Do you or will you make pre-grant inquiries about the recipient organization? If “Yes,” describe these Yes No
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.
f Do you or will you use any additional procedures to ensure that your distributions to foreign Yes No
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.
Form 1023 (Rev. 12-2017)

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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)

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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 
                       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) 
                  1  Gifts, grants, and 
                     contributions received (do not  
                     include unusual grants) 
                  2  Membership fees received 
                  3  Gross investment income 
                  4  Net unrelated business 
                     income 
                  5  Taxes levied for your benefit 
                  6  Value of services or facilities  
                     furnished by a governmental  unit 
                     without charge (not including the 
                     value of services generally furnished 
                     to the  public without charge) 
                  7  Any revenue not otherwise  listed 
         Revenues    above or in lines 9–12  below 
                     (attach an itemized list) 
                  8  Total of lines 1 through 7 
                  9  Gross receipts from admissions,  
                     merchandise sold or services  
                     performed, or furnishing of  facilities in 
                     any activity that is  related to your 
                     exempt purposes (attach itemized list) 
                  10 Total of lines 8 and 9 
                  11 Net gain or loss on sale of  
                     capital assets (attach 
                     schedule and see instructions) 
                  12  Unusual grants 
                  13 Total Revenue 
                      Add lines 10 through 12                                                                
                  14 Fundraising expenses 
                  15 Contributions, gifts, grants, 
                     and similar amounts paid out 
                     (attach an itemized list) 
                  16 Disbursements to or for the  
                     benefit of members (attach an  
                     itemized list) 
                  17 Compensation of officers,  
                     directors, and trustees 
                  18 Other salaries and wages 
         Expenses 19 Interest expense 
                  20 Occupancy (rent, utilities, etc.) 
                  21 Depreciation and depletion 
                  22 Professional fees 
                  23 Any expense not otherwise  
                     classified, such as program  
                     services (attach itemized list) 
                  24 Total Expenses 
                     Add lines 14 through 23 
                                                                                                                                         Form  1023  (Rev. 12-2017)

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

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Form 1023 (Rev. 12-2017) Name:                                                                             EIN:                                          Page  11 
Part X    Public Charity Status (Continued) 
e 509(a)(4) – an organization organized and operated exclusively for testing for public safety. 
f 509(a)(1) and 170(b)(1)(A)(iv) – an organization operated for the benefit of a college or university that is owned or 
  operated by a governmental unit.
g 509(a)(1) and 170(b)(1)(A)(ix) – an agricultural research organization directly engaged in the continuous active 
  conduct of agricultural research in conjunction with a college or university.
h 509(a)(1) and 170(b)(1)(A)(vi) – an organization that receives a substantial part of its financial support in the form
  of contributions from publicly supported organizations, from a governmental unit, or from the general public.
i 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).
j 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.
a  (i)  Enter 2% of line 8, column (e) on Part IX-A Statement of Revenues and Expenses
  (ii)  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. 

b  (i)  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.
  (ii)  For each year amounts were included on line 9 of Part IX-A Statement of Revenues and Expenses, attach a list 
        showing the name of and amount received from each payer, other than a disqualified person, whose payments 
        were more than the larger of (1) 1% of Line 10, 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                                Yes          No
  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 
You must include the correct user fee payment with this application. If you do not submit the correct user fee, we will not 
process the application and we will return it to you. Your check or money order must be made payable to the United States 
Treasury. User fees are subject to change. Check our website at www.irs.gov and type “Exempt Organizations User Fee” in 
the search box, or call Customer Account Services at 1-877-829-5500 for current information.
                         Enter the amount of the user fee paid:

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

Please   ▲
          (Signature of Officer, Director, Trustee, or other  (Type or print name of signer)                                         (Date) 
Sign      authorized official) 
Here                                                          (Type or print title or authority of signer) 

                                                                                                                Form  1023  (Rev. 12-2017)

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Form 1023 (Rev. 12-2017) Name: EIN: Page 13
Schedule A. Churches
1 a Do you have a written creed, statement of faith, or summary of beliefs? If “Yes,” attach copies of Yes No
relevant documents.

b Do you have a form of worship? If “Yes,” describe your form of worship. Yes No
2 a Do you have a formal code of doctrine and discipline? If “Yes,” describe your code of doctrine and Yes No
discipline.

b Do you have a distinct religious history? If “Yes,” describe your religious history. Yes No

c Do you have a literature of your own? If “Yes,” describe your literature. Yes No
3 Describe the organization’s religious hierarchy or ecclesiastical government.
4a Do you have regularly scheduled religious services? If “Yes,” describe the nature of the services and Yes No
provide representative copies of relevant literature such as church bulletins.

b What is the average attendance at your regularly scheduled religious services?
5a Do you have an established place of worship? If “Yes,” refer to the instructions for the information Yes No
required.

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

7 How many members do you have?
8 a Do you have a process by which an individual becomes a member? If “Yes,” describe the process and Yes No
complete lines 8b–8d, below.
b If you have members, do your members have voting rights, rights to participate in religious functions, or Yes No
other rights? If “Yes,” describe the rights your members have.

c May your members be associated with another denomination or church? Yes No

d Are all of your members part of the same family? Yes No

9 Do you conduct baptisms, weddings, funerals, etc.? Yes No

10 Do you have a school for the religious instruction of the young? Yes No
11a Do you have a minister or religious leader? If “Yes,” describe this person’s role and explain whether the Yes No
minister or religious leader was ordained, commissioned, or licensed after a prescribed course of study.

b Do you have schools for the preparation of your ordained ministers or religious leaders? Yes No

12 Is your minister or religious leader also one of your officers, directors, or trustees? Yes No
13 Do you ordain, commission, or license ministers or religious leaders? If “Yes,” describe the requirements Yes No
for ordination, commission, or licensure.
14 Are you part of a group of churches with similar beliefs and structures? If “Yes,” explain. Include the Yes No
name of the group of churches.

15 Do you issue church charters? If “Yes,” describe the requirements for issuing a charter. Yes No

16 Did you pay a fee for a church charter? If “Yes,” attach a copy of the charter. Yes No
17 Do you have other information you believe should be considered regarding your status as a church? Yes No
If “Yes,” explain.
Form 1023 (Rev. 12-2017)

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Form 1023 (Rev. 12-2017) Name: EIN: Page 14
Schedule B. Schools, Colleges, and Universities
If you operate a school as an activity, complete Schedule B
Section I Operational Information
1a Do you normally have a regularly scheduled curriculum, a regular faculty of qualified teachers, a regularly Yes No
enrolled student body, and facilities where your educational activities are regularly carried on? If “No,” do
not complete the remainder of Schedule B.
b Is the primary function of your school the presentation of formal instruction? If “Yes,” describe your Yes No
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 a Are you a public school because you are operated by a state or subdivision of a state? If “Yes,” explain Yes No
how you are operated by a state or subdivision of a state. Do not complete the remainder of Schedule B.
b Are you a public school because you are operated wholly or predominantly from government funds or Yes No
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 Yes No
school district or county?
5 Has a state or federal administrative agency or judicial body ever determined that you are racially Yes No
discriminatory? If “Yes,” explain.
6 Has your right to receive financial aid or assistance from a governmental agency ever been revoked or Yes No
suspended? If “Yes,” explain.
7 Do you or will you contract with another organization to develop, build, market, or finance your facilities? Yes No
If “Yes,” explain how that entity is selected, explain how the terms of any contracts or other agreements
are negotiated at arm’s length, and explain how you determine that you will pay no more than fair market
value for services.
Note: Make sure your answer is consistent with the information provided in Part VIII, line 7a.
8 Do you or will you manage your activities or facilities through your own employees or volunteers? If “No,” Yes No
attach a statement describing the activities that will be managed by others, the names of the persons or
organizations that manage or will manage your activities or facilities, and how these managers were or
will be selected. Also, submit copies of any contracts, proposed contracts, or other agreements
regarding the provision of management services for your activities or facilities. Explain how the terms of
any contracts or other agreements were or will be negotiated, and explain how you determine you will
pay no more than fair market value for services.
Note: Answer “Yes” if you manage or intend to manage your programs through your own employees or
by using volunteers. Answer “No” if you engage or intend to engage a separate organization or
independent contractor. Make sure your answer is consistent with the information provided in Part VIII,
line 7b.
Section II Establishment of Racially Nondiscriminatory Policy
Information required by Revenue Procedure 75-50.
1 Have you adopted a racially nondiscriminatory policy as to students in your organizing document, Yes No
bylaws, or by resolution of your governing body? If “Yes,” state where the policy can be found or supply
a copy of the policy. If “No,” you must adopt a nondiscriminatory policy as to students before submitting
this application. See Pub. 557.
2 Do your brochures, application forms, advertisements, and catalogues dealing with student admissions, Yes No
programs, and scholarships contain a statement of your racially nondiscriminatory policy?

a If “Yes,” attach a representative sample of each document.
b If “No,” by checking the box to the right you agree that all future printed materials, including website ▶
content, will contain the required nondiscriminatory policy statement.
3 Have you published a notice of your nondiscriminatory policy in a newspaper of general circulation that Yes No
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 Yes No
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.
Form 1023 (Rev. 12-2017)

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Form 1023 (Rev. 12-2017) Name:                                                  EIN:                            Page  15 
                              Schedule B. Schools, Colleges, and Universities (Continued) 
5   Complete the table below to show the racial composition for the current academic year and projected for the next academic 
    year, of: (a) the student body, (b) the faculty, and (c) the administrative staff. Provide actual numbers rather than percentages 
    for each racial category. 
    If you are not operational, submit an estimate based on the best information available (such as the racial composition of the
    community served). 
       Racial Category            (a) Student Body       (b) Faculty                      (c) Administrative Staff 
                         Current Year          Next Year Current Year Next Year      Current Year           Next Year 

    Total 

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

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

    Total 

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

b   Do any of these individuals or organizations have an objective to maintain segregated public or private Yes No
    school education? If “Yes,” explain. 

8   Will you maintain records according to the nondiscrimination provisions contained in Revenue  Procedure Yes No
    75-50? If “No,” explain. See instructions. 
                                                                                          Form  1023  (Rev. 12-2017)

- 18 -

Form 1023 (Rev. 12-2017) Name: EIN: Page 16
Schedule C. Hospitals and Medical Research Organizations
Check the box if you are a hospital. See the instructions for a definition of the term “hospital,” which includes an
organization whose principal purpose or function is providing hospital or medical care. Complete Section I below.

Check the box if you are a medical research organization operated in conjunction with a hospital. See the instructions for
a definition of the term “medical research organization,” which refers to an organization whose principal purpose or
function is medical research and which is directly engaged in the continuous active conduct of medical research in
conjunction with a hospital. Complete Section II.
Section I Hospitals
1 a Are all the doctors in the community eligible for staff privileges? If “No,” give the reasons why and Yes No
explain how the medical staff is selected.
2 a Do you or will you provide medical services to all individuals in your community who can pay for Yes No
themselves or have private health insurance? If “No,” explain.
b Do you or will you provide medical services to all individuals in your community who participate in Yes No
Medicare? If “No,” explain.
c Do you or will you provide medical services to all individuals in your community who participate in Yes No
Medicaid? If “No,” explain.
3a Do you or will you require persons covered by Medicare or Medicaid to pay a deposit before receiving Yes No
services? If “Yes,” explain.
b Does the same deposit requirement, if any, apply to all other patients? If “No,” explain. Yes No
4 a Do you or will you maintain a full-time emergency room? If “No,” explain why you do not maintain a Yes No
full-time emergency room. Also, describe any emergency services that you provide.
b Do you have a policy on providing emergency services to persons without apparent means to pay? If Yes No
“Yes,” provide a copy of the policy.
c Do you have any arrangements with police, fire, and voluntary ambulance services for the delivery or Yes No
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 a Do you provide for a portion of your services and facilities to be used for charity patients? If “Yes,” Yes No
answer 5b through 5e.
b Explain your policy regarding charity cases, including how you distinguish between charity care and bad
debts. Submit a copy of your written policy.
c Provide data on your past experience in admitting charity patients, including amounts you expend for
treating charity care patients and types of services you provide to charity care patients.
d Describe any arrangements you have with federal, state, or local governments or government agencies
for paying for the cost of treating charity care patients. Submit copies of any written agreements.
e Do you provide services on a sliding fee schedule depending on financial ability to pay? If “Yes,” submit Yes No
your sliding fee schedule.
6 a Do you or will you carry on a formal program of medical training or medical research? If “Yes,” describe Yes No
such programs, including the type of programs offered, the scope of such programs, and affiliations with
other hospitals or medical care providers with which you carry on the medical training or research
programs.
b Do you or will you carry on a formal program of community education? If “Yes,” describe such programs, Yes No
including the type of programs offered, the scope of such programs, and affiliation with other hospitals or
medical care providers with which you offer community education programs.
7 Do you or will you provide office space to physicians carrying on their own medical practices? If “Yes,” Yes No
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 Yes No
you serve? Include a list of each board member’s name and business, financial, or professional
relationship with the hospital. Also, identify each board member who is representative of the community
and describe how that individual is a community representative.
9 Do you participate in any joint ventures? If “Yes,” state your ownership percentage in each joint venture, Yes No
list your investment in each joint venture, describe the tax status of other participants in each joint
venture (including whether they are section 501(c)(3) organizations), describe the activities of each joint
venture, describe how you exercise control over the activities of each joint venture, and describe how
each joint venture furthers your exempt purposes. Also, submit copies of all agreements.
Note: Make sure your answer is consistent with the information provided in Part VIII, line 8.
Form 1023 (Rev. 12-2017)

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Form 1023 (Rev. 12-2017) Name: EIN: Page 17
Schedule C. Hospitals and Medical Research Organizations (Continued)
Section I Hospitals (Continued)
10 Do you or will you manage your activities or facilities through your own employees or volunteers? If “No,” Yes No
attach a statement describing the activities that will be managed by others, the names of the persons or
organizations that manage or will manage your activities or facilities, and how these managers were or
will be selected. Also, submit copies of any contracts, proposed contracts, or other agreements
regarding the provision of management services for your activities or facilities. Explain how the terms of
any contracts or other agreements were or will be negotiated, and explain how you determine you will
pay no more than fair market value for services.
Note: Answer “Yes” if you do manage or intend to manage your programs through your own employees
or by using volunteers. Answer “No” if you engage or intend to engage a separate organization or
independent contractor. Make sure your answer is consistent with the information provided in Part VIII,
line 7b.
11 Do you or will you offer recruitment incentives to physicians? If “Yes,” describe your recruitment Yes No
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 Yes No
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 Yes No
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 Yes No
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
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.
Form 1023 (Rev. 12-2017)

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Form 1023 (Rev. 12-2017) Name:                                                                EIN:                          Page  18 
                               Schedule D. Section 509(a)(3) Supporting Organizations 
Section I  Identifying Information About the Supported Organization(s) 
1 State the names, addresses, and EINs of the supported organizations. If additional space is needed, attach a separate sheet. 
  Name                                                                 Address                                         EIN 

2 Are all supported organizations listed in line 1 public charities under section 509(a)(1) or (2)? If “Yes,” go       Yes  No
  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)?              Yes  No
  If “Yes,” for each 501(c)(4), (5), or (6) organization supported, provide the following financial information. 
  • Part IX-A. Statement of Revenues and Expenses, lines 1–13, and 
  • Part X, lines 6b(i), 6b(ii), and 7. 
  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 
To be classified as a supporting organization, an organization must meet one of three relationship tests.
  Test 1: “Operated, supervised, or controlled by” one or more publicly supported organizations, or 
  Test 2: “Supervised or controlled in connection with” one or more publicly supported organizations, or 
  Test 3: “Operated in connection with” one or more publicly supported organizations. 
1 Information to establish the “operated, supervised, or controlled by” relationship (Test 1) 
  Is a majority of your governing board or officers elected or appointed by the supported organization(s)?             Yes  No
  If “Yes,” describe the process by which your governing board is appointed and elected; go to Section III. 
  If “No,” continue to line 2. 
2 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              Yes  No
  the supported organization(s)? If “Yes,” describe the process by which your governing board is appointed
  and elected; go to Section III. If “No,” go to line 3. 
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                  Yes  No
  under state law? If “Yes,” explain whether you advised the supported organization(s) in writing of these
  rights and provide a copy of the written communication documenting this; go to Section II, line 5. If “No,”
  go to line 4a. 
4 Information to establish the alternative “operated in connection with” responsiveness test (Test 3) 
a Do the officers, directors, trustees, or members of the supported organization(s) elect or appoint one or            Yes  No
  more of your officers, directors, or trustees? If “Yes,” explain and provide documentation; go to line 4d, 
  below. If “No,” go to line 4b. 
b Do one or more members of the governing body of the supported organization(s) also serve as your                     Yes  No
  officers, directors, or trustees or hold other important offices with respect to you? If “Yes,” explain and 
  provide documentation; go to line 4d, below. If “No,” go to line 4c. 
c Do your officers, directors, or trustees maintain a close and continuous working relationship with the               Yes  No
  officers,  directors,  or  trustees  of  the  supported  organization(s)?  If  “Yes,”  explain  and  provide 
  documentation. 
d Do the supported organization(s) have a significant voice in your investment policies, in the making and             Yes  No
  timing of grants, and in otherwise directing the use of your income or assets? If “Yes,” explain and 
  provide documentation. 
e Describe and provide copies of written communications documenting how you made the supported 
  organization(s) aware of your supporting activities. 
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)? If “Yes,”            Yes  No
  explain and go to Section III. If “No,” continue to line 6a. 
                                                                                                                 Form  1023  (Rev. 12-2017)

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Form 1023 (Rev. 12-2017) Name: EIN: Page 19
Schedule D. Section 509(a)(3) Supporting Organizations (Continued)
Section II Relationship with Supported Organization(s)—Three Tests (Continued)
6 Information to establish the alternative “operated in connection with” integral part test (Test 3)
a Do you distribute at least 85% of your annual net income to the supported organization(s)? If “Yes,” go Yes No
to line 6b. See instructions.
If “No,” state the percentage of your income that you distribute to each supported organization. Also
explain how you ensure that the supported organization(s) are attentive to your operations.
b How much do you contribute annually to each supported organization? Attach a schedule.
c What is the total annual revenue of each supported organization? If you need additional space, attach a
list.
d Do you or the supported organization(s) earmark your funds for support of a particular program or Yes No
activity? If “Yes,” explain.
7 a Does your organizing document specify the supported organization(s) by name? If “Yes,” state the article Yes No
and paragraph number and go to Section III. If “No,” answer line 7b.
b Attach a statement describing whether there has been an historic and continuing relationship between
you and the supported organization(s).
Section III Organizational Test
1a If you met relationship Test 1 or Test 2 in Section II, your organizing document must specify the Yes No
supported organization(s) by name, or by naming a similar purpose or charitable class of beneficiaries. If
your organizing document complies with this requirement, answer “Yes.” If your organizing document
does not comply with this requirement, answer “No,” and see the instructions.
b If you met relationship Test 3 in Section II, your organizing document must generally specify the Yes No
supported organization(s) by name. If your organizing document complies with this requirement, answer
“Yes,” and go to Section IV. If your organizing document does not comply with this requirement, answer
“No,” and see the instructions.
Section IV Disqualified Person Test
You do not qualify as a supporting organization if you are controlled directly or indirectly by one or more disqualified persons (as
defined in section 4946) other than foundation managers or one or more organizations that you support. Foundation managers who
are also disqualified persons for another reason are disqualified persons with respect to you.
1a Do any persons who are disqualified persons with respect to you, (except individuals who are Yes No
disqualified persons only because they are foundation managers), appoint any of your foundation
managers? If “Yes,” (1) describe the process by which disqualified persons appoint any of your
foundation managers, (2) provide the names of these disqualified persons and the foundation managers
they appoint, and (3) explain how control is vested over your operations (including assets and activities)
by persons other than disqualified persons.
b Do any persons who have a family or business relationship with any disqualified persons with respect to Yes No
you, (except individuals who are disqualified persons only because they are foundation managers),
appoint any of your foundation managers? If “Yes,” (1) describe the process by which individuals with a
family or business relationship with disqualified persons appoint any of your foundation managers,
(2) provide the names of these disqualified persons, the individuals with a family or business relationship
with disqualified persons, and the foundation managers appointed, and (3) explain how control is vested
over your operations (including assets and activities) in individuals other than disqualified persons.
c Do any persons who are disqualified persons, (except individuals who are disqualified persons only Yes No
because they are foundation managers), have any influence regarding your operations, including your
assets or activities? If “Yes,” (1) provide the names of these disqualified persons, (2) explain how
influence is exerted over your operations (including assets and activities), and (3) explain how control is
vested over your operations (including assets and activities) by individuals other than disqualified
persons.
Form 1023 (Rev. 12-2017)

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Form 1023 (Rev. 12-2017) Name: EIN: Page 20
Schedule E. Organizations Not Filing Form 1023 Within 27 Months of Formation
Schedule E is intended to determine whether you are eligible for tax exemption under section 501(c)(3) from the postmark date of your
application or from your date of incorporation or formation, whichever is earlier.
1 Are you a church, association of churches, or integrated auxiliary of a church? If “Yes,” complete Yes No
Schedule A and stop here. Do not complete the remainder of Schedule E.

2 a Are you a public charity with annual gross receipts that are normally $5,000 or less? If “Yes,” stop here. Yes No
Answer “No” if you are a private foundation, regardless of your gross receipts.
b If your gross receipts were normally more than $5,000, are you filing this application within 90 days from Yes No
the end of the tax year in which your gross receipts were normally more than $5,000? If “Yes,” stop here.
3a Were you included as a subordinate in a group exemption application or letter? If “No,” go to line 4. Yes No

b If you were included as a subordinate in a group exemption letter, are you filing this application within 27 Yes No
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.
c If you were included as a subordinate in a timely filed group exemption request that was denied, are you Yes No
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 Yes No
this schedule.
5 If you answered “No” to lines 1 through 4, we cannot recognize you as tax exempt from your date of Yes No
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 a If you answered “No” to line 5, you can only be exempt under section 501(c)(3) from the postmark date of Yes No
this application. Therefore, do you want us to treat this application as a request for tax exemption from
the postmark date?

Note: Be sure your ruling eligibility agrees with your answer to Part X, line 6.
b Do you anticipate significant changes in your sources of support in the future? If “Yes,” complete line 7 Yes No
below.

Form 1023 (Rev. 12-2017)

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Form 1023 (Rev. 12-2017) Name:                                            EIN:                Page  21 
     Schedule E. Organizations Not Filing Form 1023 Within 27 Months of Formation (Continued) 
7 Complete this item only if you answered “Yes” to line 6b. Include projected revenue for the first two full years following the 
  current tax year. 

                         Type of Revenue                      Projected revenue for 2 years following current tax year 
                                                         (a) From (b) From 
                                                                                        (c) Total 
                                                              To       To             
  1  Gifts, grants, and contributions received (do not 
     include unusual grants) 
  2  Membership fees received 

  3  Gross investment income 

  4  Net unrelated business income 

  5  Taxes levied for your benefit 

  6  Value of services or facilities furnished by a  
     governmental unit without charge (not including  
     the value of services generally furnished to the  
     public without charge) 
  7  Any revenue not otherwise listed above or in lines 
     9–12 below (attach an itemized list) 
  8  Total of lines 1 through 7 

  9  Gross receipts from admissions, merchandise  
     sold, or services performed, or furnishing of  
     facilities in any activity that is related to your  
     exempt purposes (attach itemized list) 
  10 Total of lines 8 and 9 
  11 Net gain or loss on sale of capital assets 
     (attach an itemized list) 
  12 Unusual grants 

  13 Total revenue. Add lines 10 through 12 
                                                                                  Form  1023  (Rev. 12-2017)

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Form 1023 (Rev. 12-2017) Name: EIN: Page 22
Schedule F. Homes for the Elderly or Handicapped and Low-Income Housing
Section I General Information About Your Housing
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 a Provide a description of each facility.
b What is the total number of residents each facility can accommodate?
c What is your current number of residents in each facility?
d 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? If “Yes,” state your ownership percentage in each joint venture, Yes No
list your investment in each joint venture, describe the tax status of other participants in each joint
venture (including whether they are section 501(c)(3) organizations), describe the activities of each joint
venture, describe how you exercise control over the activities of each joint venture, and describe how
each joint venture furthers your exempt purposes. Also, submit copies of all joint venture agreements.

Note: Make sure your answer is consistent with the information provided in Part VIII, line 8.
7 Do you or will you contract with another organization to develop, build, market, or finance your housing? Yes No
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.

Note: Make sure your answer is consistent with the information provided in Part VIII, line 7a.
8 Do you or will you manage your activities or facilities through your own employees or volunteers? If “No,” Yes No
attach a statement describing the activities that will be managed by others, the names of the persons or
organizations that manage or will manage your activities or facilities, and how these managers were or
will be selected. Also, submit copies of any contracts, proposed contracts, or other agreements
regarding the provision of management services for your activities or facilities. Explain how the terms of
any contracts or other agreements were or will be negotiated, and explain how you determine you will
pay no more than fair market value for services.
Note: Answer “Yes” if you do manage or intend to manage your programs through your own employees
or by using volunteers. Answer “No” if you engage or intend to engage a separate organization or
independent contractor. Make sure your answer is consistent with the information provided in Part VIII,
line 7b.
9 Do you participate in any government housing programs? If “Yes,” describe these programs. Yes No
10 a Do you own the facility? If “No,” describe any enforceable rights you possess to purchase the facility in Yes No
the future; go to line 10c. If “Yes,” answer line 10b.
b How did you acquire the facility? For example, did you develop it yourself, purchase a project, etc.
Attach all contracts, transfer agreements, or other documents connected with the acquisition of the
facility.
c Do you lease the facility or the land on which it is located? If “Yes,” describe the parties to the lease(s) Yes No
and provide copies of all leases.
Form 1023 (Rev. 12-2017)

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Form 1023 (Rev. 12-2017) Name: EIN: Page 23
Schedule F. Homes for the Elderly or Handicapped and Low-Income Housing (Continued)
Section II Homes for the Elderly or Handicapped
1a Do you provide housing for the elderly? If “Yes,” describe who qualifies for your housing in terms of age, Yes No
infirmity, or other criteria and explain how you select persons for your housing.
b Do you provide housing for the handicapped? If “Yes,” describe who qualifies for your housing in terms Yes No
of disability, income levels, or other criteria and explain how you select persons for your housing.
2 a Do you charge an entrance or founder’s fee? If “Yes,” describe what this charge covers, whether it is a Yes No
one-time fee, how the fee is determined, whether it is payable in a lump sum or on an installment basis,
whether it is refundable, and the circumstances, if any, under which it may be waived.
b Do you charge periodic fees or maintenance charges? If “Yes,” describe what these charges cover and Yes No
how they are determined.
c Is your housing affordable to a significant segment of the elderly or handicapped persons in the Yes No
community? Identify your community. Also, if “Yes,” explain how you determine your housing is
affordable.
3 a Do you have an established policy concerning residents who become unable to pay their regular Yes No
charges? If “Yes,” describe your established policy.
b Do you have any arrangements with government welfare agencies or others to absorb all or part of the Yes No
cost of maintaining residents who become unable to pay their regular charges? If “Yes,” describe these
arrangements.

4 Do you have arrangements for the healthcare needs of your residents? If “Yes,” describe these Yes No
arrangements.

5 Are your facilities designed to meet the physical, emotional, recreational, social, religious, and/or other Yes No
similar needs of the elderly or handicapped? If “Yes,” describe these design features.

Section III Low-Income Housing

1 Do you provide low-income housing? If “Yes,” describe who qualifies for your housing in terms of Yes No
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? If Yes No
“Yes,” describe what these charges cover and how they are determined.

3 a Is your housing affordable to low income residents? If “Yes,” describe how your housing is made Yes No
affordable to low-income residents.
Note: Revenue Procedure 96-32, 1996-1 C.B. 717, provides guidelines for providing low-income housing
that will be treated as charitable. (At least 75% of the units are occupied by low-income tenants or 40%
are occupied by tenants earning not more than 120% of the very low-income levels for the area.)

b Do you impose any restrictions to make sure that your housing remains affordable to low-income Yes No
residents? If “Yes,” describe these restrictions.

4 Do you provide social services to residents? If “Yes,” describe these services. Yes No

Form 1023 (Rev. 12-2017)

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Form 1023 (Rev. 12-2017) Name: EIN: Page 24
Schedule G. Successors to Other Organizations
1 a Are you a successor to a for-profit organization? If “Yes,” explain the relationship with the Yes No
predecessor organization that resulted in your creation and complete line 1b.
b Explain why you took over the activities or assets of a for-profit organization or converted from for-profit
to nonprofit status.
2a Are you a successor to an organization other than a for-profit organization? Answer “Yes” if you have Yes No
taken or will take over the activities of another organization; or you have taken or will take over 25% or
more of the fair market value of the net assets of another organization. If “Yes,” explain the relationship
with the other organization that resulted in your creation.
b Provide the tax status of the predecessor organization.
c Did you or did an organization to which you are a successor previously apply for tax exemption under Yes No
section 501(c)(3) or any other section of the Code? If “Yes,” explain how the application was resolved.
d Was your prior tax exemption or the tax exemption of an organization to which you are a successor Yes No
revoked or suspended? If “Yes,” explain. Include a description of the corrections you made to
re-establish tax exemption.
e Explain why you took over the activities or assets of another organization.
3 Provide the name, last address, and EIN of the predecessor organization and describe its activities.
Name: EIN:
Address:

4 List the owners, partners, principal stockholders, officers, and governing board members of the predecessor organization.
Attach a separate sheet if additional space is needed.
Name Address Share/Interest (If a for-profit)

5 Do or will any of the persons listed in line 4, maintain a working relationship with you? If “Yes,” describe Yes No
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.
6a Were any assets transferred, whether by gift or sale, from the predecessor organization to you? If “Yes,” Yes No
provide a list of assets, indicate the value of each asset, explain how the value was determined, and
attach an appraisal, if available. For each asset listed, also explain if the transfer was by gift, sale, or
combination thereof.
b Were any restrictions placed on the use or sale of the assets? If “Yes,” explain the restrictions. Yes No

c Provide a copy of the agreement(s) of sale or transfer.
7 Were any debts or liabilities transferred from the predecessor for-profit organization to you? Yes No
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 Yes No
organization, or from persons listed in line 4, or from for-profit organizations in which these persons own
more than a 35% interest? If “Yes,” submit a copy of the lease or rental agreement(s). Indicate how the
lease or rental value of the property or equipment was determined.
9 Will you lease or rent property or equipment to persons listed in line 4, or to for-profit organizations in Yes No
which these persons own more than a 35% interest? If “Yes,” attach a list of the property or equipment,
provide a copy of the lease or rental agreement(s), and indicate how the lease or rental value of the
property or equipment was determined.
Form 1023 (Rev. 12-2017)

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Form 1023 (Rev. 12-2017) Name:                                                               EIN:                            Page  25 
Schedule H. Organizations Providing Scholarships, Fellowships, Educational Loans, or Other Educational Grants 
to Individuals and Private Foundations Requesting Advance Approval of Individual Grant Procedures 
Section I  Names of individual recipients are not required to be listed in Schedule H. 
           Public charities and private foundations complete lines 1a through 7 of this section. See the  
           instructions to Part X if you are not sure whether you are a public charity or a private foundation. 
1 a Describe the types of educational grants you provide to individuals, such as scholarships, fellowships, loans, etc. 
b   Describe the purpose and amount of your scholarships, fellowships, and other educational grants and loans that 
    you award. 
c   If you award educational loans, explain the terms of the loans (interest rate, length, forgiveness, etc.). 
d   Specify how your program is publicized. 
e   Provide copies of any solicitation or announcement materials. 
f   Provide a sample copy of the application used. 
2   Do you maintain case histories showing recipients of your scholarships, fellowships, educational loans, or          Yes  No
    other educational grants, including names, addresses, purposes of awards, amount of each grant, 
    manner of selection, and relationship (if any) to officers, trustees, or donors of funds to you? If “No,” refer 
    to the instructions. 
3   Describe the specific criteria you use to determine who is eligible for your program. (For example, eligibility 
    selection criteria could consist of graduating high school students from a particular high school who will attend 
    college, writers of scholarly works about American history, etc.) 
4 a Describe the specific criteria you use to select recipients. (For example, specific selection criteria could consist of
    prior academic performance, financial need, etc.) 
b   Describe how you determine the number of grants that will be made annually. 
c   Describe how you determine the amount of each of your grants. 
d   Describe any requirement or condition that you impose on recipients to obtain, maintain, or qualify for renewal of a 
    grant. (For example, specific requirements or conditions could consist of attendance at a four-year college, 
    maintaining a certain grade point average, teaching in public school after graduation from college, etc.) 
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           Yes  No
    contributors eligible for awards made under your program? If “Yes,” what measures are taken to ensure 
    unbiased selections? 
    Note: If you are a private foundation, you are not permitted to provide educational grants to disqualified 
    persons.  Disqualified  persons  include  your  substantial  contributors  and  foundation  managers  and 
    certain family members of disqualified persons. 
Section II Private foundations complete lines 1a through 4f of this section. Public charities do not  complete 
           this section. 
1a  If  we  determine  that  you  are  a  private  foundation,  do  you  want  this  application  to  be   Yes          No   N/A
    considered as a request for advance approval of grant making procedures? 
b   For which section(s) do you wish to be considered? 
    •  4945(g)(1)—Scholarship or fellowship grant to an individual for study at an educational institution 
    •  4945(g)(3)—Other  grants,  including  loans,  to  an  individual  for  travel,  study,  or  other  similar 
     purposes, to enhance a particular skill of the grantee or to produce a specific product 
2   Do you represent that you will (1) arrange to receive and review grantee reports annually and          Yes          No
    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           Yes          No
    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? 
                                                                                                                  Form  1023  (Rev. 12-2017)

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Form 1023 (Rev. 12-2017) Name: EIN: Page 26
Schedule H. Organizations Providing Scholarships, Fellowships, Educational Loans, or Other Educational Grants
to Individuals and Private Foundations Requesting Advance Approval of Individual Grant Procedures (Continued)
Section II Private foundations complete lines 1a through 4f of this section. Public charities do not complete
this section. (Continued)
4 a Do you or will you award scholarships, fellowships, and educational loans to attend an Yes No
educational institution based on the status of an individual being an employee of a particular
employer? If “Yes,” complete lines 4b through 4f.
b Will you comply with the seven conditions and either the percentage tests or facts and Yes No
circumstances test for scholarships, fellowships, and educational loans to attend an
educational institution as set forth in Revenue Procedures 76-47, 1976-2 C.B. 670, and 80-39,
1980-2 C.B. 772, which apply to inducement, selection committee, eligibility requirements,
objective basis of selection, employment, course of study, and other objectives? (See lines 4c,
4d, and 4e, regarding the percentage tests.)
c Do you or will you provide scholarships, fellowships, or educational loans to attend an Yes No N/A
educational institution to employees of a particular employer?
If “Yes,” will you award grants to 10% or fewer of the eligible applicants who were actually Yes No
considered by the selection committee in selecting recipients of grants in that year as provided
by Revenue Procedures 76-47 and 80-39?
d Do you provide scholarships, fellowships, or educational loans to attend an educational Yes No N/A
institution to children of employees of a particular employer?
If “Yes,” will you award grants to 25% or fewer of the eligible applicants who were actually Yes No
considered by the selection committee in selecting recipients of grants in that year as provided
by Revenue Procedures 76-47 and 80-39? If “No,” go to line 4e.
e If you provide scholarships, fellowships, or educational loans to attend an educational Yes No N/A
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?
If “Yes,” describe how you will determine who can be shown to be eligible for grants without
submitting an application, such as by obtaining written statements or other information about
the expectations of employees’ children to attend an educational institution. If “No,” go to line
4f.
Note: Statistical or sampling techniques are not acceptable. See Revenue Procedure
85-51, 1985-2 C.B. 717, for additional information.
f If you provide scholarships, fellowships, or educational loans to attend an educational Yes No
institution to children of employees of a particular employer without regard to either the 25%
limitation described in line 4d, or the 10% limitation described in line 4e, will you award grants
based on facts and circumstances that demonstrate that the grants will not be considered
compensation for past, present, or future services or otherwise provide a significant benefit to
the particular employer? If “Yes,” describe the facts and circumstances that you believe will
demonstrate that the grants are neither compensatory nor a significant benefit to the particular
employer. In your explanation, describe why you cannot satisfy either the 25% test described
in line 4d or the 10% test described in line 4e.
Form 1023 (Rev. 12-2017)

- 29 -

Form 1023 Checklist

(Revised December 2017)

Application for Recognition of Exemption under Section 501(c)(3) of the
Internal Revenue Code

Note: Retain a copy of the completed Form 1023 in your permanent records. Refer to theGeneral Instructionsregarding
Public Inspection of approved applications.

Check each box to finish your application (Form 1023). Send this completed Checklist with your filled-in
application. If you have not answered all the items below, your application may be returned to you as
incomplete.

Assemble the application and materials in this order.
• Form 1023 Checklist
• Form 2848, Power of Attorney and Declaration of Representative (if filing)
• Form 8821, Tax Information Authorization (if filing)
• Expedite request (if requesting)
• Application (Form 1023 and Schedules A through H, as required)
• Articles of organization
• Amendments to articles of organization in chronological order
• Bylaws or other rules of operation and amendments
• Documentation of nondiscriminatory policy for schools, as required by Schedule B
• Form 5768, Election/Revocation of Election by an Eligible Section 501(c)(3) Organization To Make
Expenditures To Influence Legislation (if filing)
• All other attachments, including explanations, financial data, and printed materials or publications.
Label each page with name and EIN.

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

Employer Identification Number (EIN)

Completed Parts I through XI of the application, including any requested information and any
required Schedules A through H.
• You must provide specific details about your past, present, and planned activities.
• Generalizations or failure to answer questions in the Form 1023 application will prevent us from
recognizing you as tax exempt.
• Describe your purposes and proposed activities in specific easily understood terms.
• Financial information should correspond with proposed activities.

Schedules. Submit only those schedules that apply to you and check either “Yes” or “No” below.

Schedule A Yes No Schedule E Yes No

Schedule B Yes No Schedule F Yes No

Schedule C Yes No Schedule G Yes No

Schedule D Yes No Schedule H Yes No

- 30 -

An exact copy of your complete articles of organization (creating document). Absence of the proper purpose  
and dissolution clauses is the number one reason for delays in the issuance of determination letters. 
• Location of Purpose Clause from Part III, line 1 (Page, Article and Paragraph Number) 
• Location of Dissolution Clause from Part III, line 2b or 2c (Page, Article and Paragraph Number) or by 
   operation of state law 

Signature of an officer, director, trustee, or other official who is authorized to sign the application. 
• Signature at Part XI of Form 1023. 

Your name on the application must be the same as your legal name as it appears in your articles of  
organization. 

Send completed Form 1023, user fee payment, and all other required information, to: 

Internal Revenue Service 
Attention: EO Determination Letters 
Stop 31 
P.O. Box 12192 
Covington, KY 41012-0192

If you are using express mail or a delivery service, send Form 1023, user fee payment, and attachments to: 

Internal Revenue Service 
Attention: EO Determination Letters 
Stop 31 
201 West Rivercenter Boulevard 
Covington, KY 41011

PDF file checksum: 753151554

(Plugin #1/8.13/12.0)