• Part V

  • Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees, Part V 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.

  • 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.

  • 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.

  • 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 relationships? If “Yes,” identify the individuals and explain the relationship

  • b - Do you have a business relationship with any of your officers, directors, or trustees other than through their position as an officer, director, or trustee? If “Yes,” identify the individuals and describe the business relationship with each of your officers, directors, or trustees.

  • c - Are any of your officers, directors, or trustees related to your highest compensated employees or highest compensated independent contractors listed on lines 1b or 1c through family or business relationships? If “Yes,” identify the individuals and explain the relationship.

  • 3a - For each of your officers, directors, trustees, highest compensated employees, and highest compensated independent contractors listed on lines 1a, 1b, or 1c, attach a list showing their name, qualifications, average hours worked, and duties.

  • b - Do any of your officers, directors, trustees, highest compensated employees, and highest compensated independent contractors listed on lines 1a, 1b, or 1c receive compensation from any other organizations, whether tax exempt or taxable, that are related to you through common control? If “Yes,” identify the individuals, explain the relationship between you and the other organization, and describe the compensation arrangement.

  • 4 - In establishing the compensation for your officers, directors, trustees, highest compensated employees, and highest compensated independent contractors listed on lines 1a, 1b, and 1c, the following practices are recommended, although they are not required to obtain exemption. Answer “Yes” to all the practices you use.

  • a - Do you or will the individuals that approve compensation arrangements follow a conflict of interest policy?

  • b - Do you or will you approve compensation arrangements in advance of paying compensation?

  • c - Do you or will you document in writing the date and terms of approved compensation arrangements?

  • d - Do you or will you record in writing the decision made by each individual who decided or voted on compensation arrangements?

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

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

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

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

  • b - Do you or will you sell any goods, services, or assets to any of your officers, directors, trustees, highest 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, 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 Yes No which any of your officers, directors, or trustees are also officers, directors, or trustees, or in which any individual officer, director, or trustee owns more than a 35% interest? If “Yes,” provide the information requested in lines 9b through 9f.

  • 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.)

  • 1a - In carrying out your exempt purposes, do you provide goods, services, or funds to individuals? If “Yes,” describe each program that provides goods, services, or funds to individuals.

  • b - In carrying out your exempt purposes, do you provide goods, services, or funds to organizations? If “Yes,” describe each program that provides goods, services, or funds to organizations.

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

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

  • Part VII

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

  • The following “Yes” or “No” questions relate to your history. (See instructions.)

  • 1 - Are you a successor to another organization? Answer “Yes,” if you have taken or will take over the activities of another organization; you took over 25% or more of the fair market value of the net assets of another organization; or you were established upon the conversion of an organization from for-profit to non-profit status. If “Yes,” complete Schedule G.

  • 2 - Are you submitting this application more than 27 months after the end of the month in which you were legally formed? If “Yes,” complete Schedule E.

  • Part VIII

  • 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.

  • 2a - Do you attempt to influence legislation? If “Yes,” explain how you attempt to influence legislation and complete line 2b. If “No,” go to line 3a.

  • b - Have you made or are you making an election to have your legislative activities measured by expenditures by filing Form 5768? If “Yes,” attach a copy of the Form 5768 that was already filed or attach a completed Form 5768 that you are filing with this application. If “No,” describe whether your attempts to influence legislation are a substantial part of your activities. Include the time and money spent on your attempts to influence legislation as compared to your total activities.

  • 3a - Do you or will you operate bingo or gaming activities? If “Yes,” describe who conducts them, and list all revenue received or expected to be received and expenses paid or expected to be paid in operating these activities. Revenue and expenses should be provided for the time periods specified in Part IX, Financial Data.

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

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

  • 4a - Do you or will you undertake fundraising? If “Yes,” check all the fundraising programs you do or will conduct. (See instructions.)

  • Attach a description of each fundraising program.

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

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

  • d - List all states and local jurisdictions in which you conduct fundraising. For each state or local jurisdiction listed, specify whether you fundraise for your own organization, you fundraise for another organization, or another organization fundraises for you.

  • e - Do you or will you maintain separate accounts for any contributor under which the contributor has the right to advise on the use or distribution of funds? Answer “Yes” if the donor may provide advice on the types of investments, distributions from the types of investments, or the distribution from the donor’s contribution account. If “Yes,” describe this program, including the type of advice that may be provided and submit copies of any written materials provided to donors.

  • 5 - Are you affiliated with a governmental unit? If “Yes,” explain.

  • 6a - Do you or will you engage in economic development? If “Yes,” describe your program.

  • b - Describe in full who benefits from your economic development activities and how the activities promote exempt purposes.

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

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

  • 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 treated as partnerships, in which you share profits and losses with partners other than section 501(c)(3) organizations? If “Yes,” describe the activities of these joint ventures in which you participate.

  • 9a - Are you applying for exemption as a childcare organization under section 501(k)? If “Yes,” answer lines 9b through 9d. If “No,” go to line 10.

  • b - Do you provide child care so that parents or caretakers of children you care for can be gainfully employed (see instructions)? If “No,” explain how you qualify as a childcare organization described in section 501(k).

  • c - Of the children for whom you provide child care, are 85% or more of them cared for by you to enable their parents or caretakers to be gainfully employed (see instructions)? If “No,” explain how you qualify as a childcare organization described in section 501(k).

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

  • 10 - Do you or will you publish, own, or have rights in music, literature, tapes, artworks, choreography, scientific discoveries, or other intellectual property? If “Yes,” explain. 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.

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

  • 12a - Do you or will you operate in a foreign country or countries? If “Yes,” answer lines 12b through 12d. If “No,” go to line 13a.

  • b - Name the foreign countries and regions within the countries in which you operate.

  • c - Describe your operations in each country and region in which you operate.

  • d - Describe how your operations in each country and region further your exempt purposes.

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

  • 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.

  • 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.

  • (ii) - Do you require a grant proposal? If “Yes,” describe whether the grant proposal specifies your responsibilities and those of the grantee, obligates the grantee to use the grant funds only for the purposes for which the grant was made, provides for periodic written reports concerning the use of grant funds, requires a final written report and an accounting of how grant funds were used, and acknowledges your authority to withhold and/or recover grant funds in case such funds are, or appear to be, misused.

  • 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.

  • 14a - Do you or will you make grants, loans, or other distributions to foreign organizations? If “Yes,” answer lines 14b through 14f. If “No,” go to line 15.

  • b - Provide the name of each foreign organization, the country and regions within a country in which each foreign organization operates, and describe any relationship you have with each foreign organization.

  • c - Does any foreign organization listed in line 14b accept contributions earmarked for a specific country or specific organization? If “Yes,” list all earmarked organizations or countries.

  • d - Do your contributors know that you have ultimate authority to use contributions made to you at your discretion for purposes consistent with your exempt purposes? If “Yes,” describe how you relay this information to contributors.

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

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

  • 15 - Do you have a close connection with any organizations? If “Yes,” explain.

  • 16 - Are you applying for exemption as a cooperative hospital service organization under section 501(e)? If “Yes,” explain.

  • 17 - Are you applying for exemption as a cooperative service organization of operating educational organizations under section 501(f)? If “Yes,” explain.

  • 18 - Are you applying for exemption as a charitable risk pool under section 501(n)? If “Yes,” explain.

  • 19 - Do you or will you operate a school? If “Yes,” complete Schedule B. Answer “Yes,” whether you operate 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.

  • 21 - Do you or will you provide low-income housing or housing for the elderly or handicapped? If “Yes,” complete Schedule F.

  • 22 - Do you or will you provide scholarships, fellowships, educational loans, or other educational grants to individuals, including grants for travel, study, or other similar purposes? If “Yes,” complete Schedule H.

  • Note: - Private foundations may use Schedule H to request advance approval of individual grant procedures.

  • Part IX

  • Financial Data

  • For purposes of this schedule, years in existence refer to completed tax years. If in existence 4 or more years, complete the schedule for the most recent 4 tax years. If in existence more than 1 year but less than 4 years, complete the statements for each year in existence and provide projections of your likely revenues and expenses based on a reasonable and good faith estimate of your future finances for a total of 3 years of financial information. If in existence less than 1 year, provide projections of your likely revenues and expenses for the current year and the 2 following years, based on a reasonable and good faith estimate of your future finances for a total of 3 years of financial information. (See instructions.)

  • A. Statement of Revenues and Expenses

  • Type of revenue or expense

    Current tax year

    (a) From-------

    To-------

    3 prior tax years or 2 succeeding tax years

    (b) From-------

    To-------

    (c) From-------

    To-------

    (d) From-------

    To-------

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

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

    Row 1 Column 2

    Row 1 Column 3

    Row 1 Column 4

    2. Membership fees received

    Row 2 Column 2

    Row 2 Column 3

    Row 2 Column 4

  • 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.)

  • 1a - Are you a private foundation? If “Yes,” go to line 1b. If “No,” go to line 5 and proceed as instructed. If you are unsure, see the instructions.

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

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

  • 3 - Have you existed for one or more years? If “Yes,” attach financial information showing that you are a private operating foundation; go to the signature section of Part XI. If “No,” continue to line 4.

  • 4 - Have you attached either (1) an affidavit or opinion of counsel, (including a written affidavit or opinion from a certified public accountant or accounting firm with expertise regarding this tax law matter), that sets forth facts concerning your operations and support to demonstrate that you are likely to satisfy the requirements to be classified as a private operating foundation; or (2) a statement describing your proposed operations as a private operating foundation?

  • 5 - If you answered “No” to line 1a, indicate the type of public charity status you are requesting by checking one of the choices below. You may check only one box. The organization is not a private foundation because it is:

  • a - 509(a)(1) and 170(b)(1)(A)(i)—a church or a convention or association of churches. Complete and attach Schedule A.

  • b - 509(a)(1) and 170(b)(1)(A)(ii)—a school. Complete and attach Schedule B.

  • c - 509(a)(1) and 170(b)(1)(A)(iii)—a hospital, a cooperative hospital service organization, or a medical research organization operated in conjunction with a hospital. Complete and attach Schedule C.

  • d - 509(a)(3)—an organization supporting either one or more organizations described in line 5a through c, f, g, or h or a publicly supported section 501(c)(4), (5), or (6) organization. Complete and attach Schedule D.

  • 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)(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.

  • h - 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).

  • i - A publicly supported organization, but unsure if it is described in 5g or 5h. The organization would like the IRS to decide the correct status.

  • 6 - If you checked box g, h, or i in question 5 above, you must request either an advance or a definitive ruling by selecting one of the boxes below. Refer to the instructions to determine which type of ruling you are eligible to receive.

  • a - Request for Advance Ruling: By checking this box and signing the consent, pursuant to section 6501(c)(4) of the Code you request an advance ruling and agree to extend the statute of limitations on the assessment of excise tax under section 4940 of the Code. The tax will apply only if you do not establish public support status at the end of the 5-year advance ruling period. The assessment period will be extended for the 5 advance ruling years to 8 years, 4 months, and 15 days beyond the end of the first year. You have the right to refuse or limit the extension to a mutually agreed-upon period of time or issue(s). Publication 1035, Extending the Tax Assessment Period, provides a more detailed explanation of your rights and the consequences of the choices you make. You may obtain Publication 1035 free of charge from the IRS web site at www.irs.gov or by calling toll-free 1-800-829-3676. Signing this consent will not deprive you of any appeal rights to which you would otherwise be entitled. If you decide not to extend the statute of limitations, you are not eligible for an advance ruling.

  • Consent Fixing Period of Limitations Upon Assessment of Tax Under Section 4940 of the Internal Revenue Code

  • For Organization

  • (Signature of Officer, Director, Trustee, or other authorized official)
  • (Type or print name of signer)
  • (Type or print title or authority of signer)
  • Date
  • For IRS Use Only

  • IRS Director, Exempt Organizations
  • Date
  • b - Request for Definitive Ruling: Check this box if you have completed one tax year of at least 8 full months and you are requesting a definitive ruling. To confirm your public support status, answer line 6b(i) if you checked box g in line 5 above. Answer line 6b(ii) if you checked box h in line 5 above. If you checked box i in line 5 above, answer both lines 6b(i) and (ii).

  • (i) - (a)Request for Definitive Ruling: Enter 2% of line 8, column (e) on Part IX-A. Statement of Revenues and Expenses.

  • b - Attach a list showing the name and amount contributed by each person, company, or organization whose gifts totaled more than the 2% amount. If the answer is “None,” check this box.

  • (ii) - (a) For each year amounts are included on lines 1, 2, and 9 of Part IX-A. Statement of Revenues and Expenses, attach a list showing the name of and amount received from each disqualified person. If the answer is “None,” check this box.

  • (b) - For each year amounts are included on line 9 of Part IX-A. Statement of Revenues and Expenses, attach a list showing the name of and amount received from each payer, other than a disqualified person, whose payments were more than the larger of (1) 1% of line 10, Part IX-A. Statement of Revenues and Expenses, or (2) $5,000. If the answer is “None,” check this box.

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

  • Part XI

  • User Fee Information

  • You must include a user fee payment with this application. It will not be processed without your paid user fee. If your average annual gross receipts have exceeded or will exceed $10,000 annually over a 4-year period, you must submit payment of $850. If your gross receipts have not exceeded or will not exceed $10,000 annually over a 4-year period, the required user fee payment is $400. See instructions for Part XI, for a definition of gross receipts over a 4-year period. Your check or money order must be made payable to the United States Treasury. User fees are subject to change. Check our website at www.irs.gov and type “User Fee” in the keyword box, or call Customer Account Services at 1-877-829-5500 for current information.

  • 1 - Have your annual gross receipts averaged or are they expected to average not more than $10,000?

  • If “Yes,” check the box on line 2 and enclose a user fee payment of $400 (Subject to change—see above).

  • If “No,” check the box on line 3 and enclose a user fee payment of $850 (Subject to change—see above).

  • 2 - Check the box if you have enclosed the reduced user fee payment of $400 (Subject to change).

  • 3 - Check the box if you have enclosed the user fee payment of $850 (Subject to change).

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

  • Please Sign Here

  • Signature of Officer, Director, Trustee, or other authorized official)
  • (Type or print name of signer)
  • (Type or print title or authority of signer)
  • Date
  • Reminder:

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

  • Schedule A. Churches

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

  • b - Do you have a form of worship? If “Yes,” describe your form of worship.

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

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

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

  • 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 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 required.

  • b - Do you own the property where you have an established place of worship?

  • 6 - Do you have an established congregation or other regular membership group? If “No,” refer to the instructions.

  • 7 - How many members do you have?

  • 8a - Do you have a process by which an individual becomes a member? If “Yes,” describe the process and complete lines 8b–8d, below.

  • b - If you have members, do your members have voting rights, rights to participate in religious functions, or other rights? If “Yes,” describe the rights your members have.

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

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

  • 9 - Do you conduct baptisms, weddings, funerals, etc.?

  • 10 - Do you have a school for the religious instruction of the young?

  • 11a - Do you have a minister or religious leader? If “Yes,” describe this person’s role and explain whether the minister or religious leader was ordained, commissioned, or licensed after a prescribed course of study.

  • b - Do you have schools for the preparation of your ordained ministers or religious leaders?

  • 12 - Is your minister or religious leader also one of your officers, directors, or trustees?

  • 13 - Do you ordain, commission, or license ministers or religious leaders? If “Yes,” describe the requirements for ordination, commission, or licensure.

  • 14 - Are you part of a group of churches with similar beliefs and structures? If “Yes,” explain. Include the name of the group of churches.

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

  • 16 - Did you pay a fee for a church charter? If “Yes,” attach a copy of the charter.

  • 17 - Do you have other information you believe should be considered regarding your status as a church? If “Yes,” explain.

  • Schedule B. 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 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 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.

  • 2a - Are you a public school because you are operated by a state or subdivision of a state? If “Yes,” explain how you are operated by a state or subdivision of a state. Do not complete the remainder of Schedule B.

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

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

  • 4 - Were you formed or substantially expanded at the time of public school desegregation in the above school district or county?

  • 5 - Has a state or federal administrative agency or judicial body ever determined that you are racially discriminatory? If “Yes,” explain.

  • 6 - Has your right to receive financial aid or assistance from a governmental agency ever been revoked or suspended? If “Yes,” explain.

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

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

  • 8 - Do you or will you manage your activities or facilities through your own employees or volunteers? If “No,” attach a statement describing the activities that will be managed by others, the names of the persons or organizations that manage or will manage your activities or facilities, and how these managers were or will be selected. Also, submit copies of any contracts, proposed contracts, or other agreements regarding the provision of management services for your activities or facilities. Explain how the terms of any contracts or other agreements were or will be negotiated, and explain how you determine you will pay no more than fair market value for services.

    Note. Answer “Yes” if you manage or intend to manage your programs through your own employees or by using volunteers. Answer “No” if you engage or intend to engage a separate organization or independent contractor. Make sure your answer is consistent with the information provided in Part VIII, line 7b.

  • Section II

  • 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, bylaws, or by resolution of your governing body? If “Yes,” state where the policy can be found or supply a copy of the policy. If “No,” you must adopt a nondiscriminatory policy as to students before submitting this application. See Publication 557.

  • 2 - Do your brochures, application forms, advertisements, and catalogues dealing with student admissions, programs, and scholarships contain a statement of your racially nondiscriminatory policy?

  • a - If “Yes,” attach a representative sample of each document.

  • b - If “No,” by checking the box to the right you agree that all future printed materials, including website content, will contain the required nondiscriminatory policy statement.

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

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

  • 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

  • 1a - Are all the doctors in the community eligible for staff privileges? If “No,” give the reasons why and explain how the medical staff is selected.

  • 2a - Do you or will you provide medical services to all individuals in your community who can pay for themselves or have private health insurance? If “No,” explain.

  • b - Do you or will you provide medical services to all individuals in your community who participate in Medicare? If “No,” explain.

  • c - Do you or will you provide medical services to all individuals in your community who participate in Medicaid? If “No,” explain.

  • 3a - Do you or will you require persons covered by Medicare or Medicaid to pay a deposit before receiving services? If “Yes,” explain.

  • b - Does the same deposit requirement, if any, apply to all other patients? If “No,” explain.

  • 4a - Do you or will you maintain a full-time emergency room? If “No,” explain why you do not maintain a full-time emergency room. Also, describe any emergency services that you provide.

  • b - Do you have a policy on providing emergency services to persons without apparent means to pay? If “Yes,” provide a copy of the policy.

  • c - Do you have any arrangements with police, fire, and voluntary ambulance services for the delivery or admission of emergency cases? If “Yes,” describe the arrangements, including whether they are written or oral agreements. If written, submit copies of all such agreements.

  • 5a - Do you provide for a portion of your services and facilities to be used for charity patients? If “Yes,” answer 5b through 5e.

  • b - Explain your policy regarding charity cases, including how you distinguish between charity care and bad debts. Submit a copy of your written policy.

  • c - Provide data on your past experience in admitting charity patients, including amounts you expend for treating charity care patients and types of services you provide to charity care patients.

  • d - Describe any arrangements you have with federal, state, or local governments or government agencies for paying for the cost of treating charity care patients. Submit copies of any written agreements.

  • e - Do you provide services on a sliding fee schedule depending on financial ability to pay? If “Yes,” submit your sliding fee schedule.

  • 6a - Do you or will you carry on a formal program of medical training or medical research? If “Yes,” describe such programs, including the type of programs offered, the scope of such programs, and affiliations with other hospitals or medical care providers with which you carry on the medical training or research programs.

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

  • 7 - Do you or will you provide office space to physicians carrying on their own medical practices? If “Yes,” describe the criteria for who may use the space, explain the means used to determine that you are paid at least fair market value, and submit representative lease agreements.

  • 8 - Is your board of directors comprised of a majority of individuals who are representative of the community you serve? Include a list of each board member’s name and business, financial, or professional relationship with the hospital. 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, 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.

  • 10 - Do you or will you manage your activities or facilities through your own employees or volunteers? If “No,” attach a statement describing the activities that will be managed by others, the names of the persons or organizations that manage or will manage your activities or facilities, and how these managers were or will be selected. 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 incentives and attach copies of all written recruitment incentive policies.

  • 12 - Do you or will you lease equipment, assets, or office space from physicians who have a financial or professional relationship with you? If “Yes,” explain how you establish a fair market value for the lease.

  • 13 - Have you purchased medical practices, ambulatory surgery centers, or other business assets from physicians or other persons with whom you have a business relationship, aside from the purchase? If “Yes,” submit a copy of each purchase and sales contract and describe how you arrived at fair market value, including copies of appraisals.

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

  • Section II

  • Medical Research Organizations

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

  • 2 - Attach a schedule describing your present and proposed activities for the direct conduct of medical research; describe the nature of the activities, and the amount of money that has been or will be spent in carrying them out.

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

  • Schedule D. Section 509(a)(3) Supporting Organizations

  • Section I

  • Identifying Information About the Supported Organization(s)

  • 1 - State the names, addresses, and EINs of the supported organizations. If additional space is needed, attach a separate sheet.

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

  • 3 - Do the supported organizations have tax-exempt status under section 501(c)(4), 501(c)(5), or 501(c)(6)?

  • If “Yes,” for each 501(c)(4), (5), or (6) organization supported, provide the following financial information:

    ● Part IX-A. Statement of Revenues and Expenses, lines 1–13 and

    ● Part X, lines 6b(ii)(a), 6b(ii)(b), and 7.

  • If “No,” attach a statement describing how each organization you support is a public charity under section 509(a)(1) or (2).

  • Section II

  • Relationship with Supported Organization(s)—Three Tests

  • To be classified as a supporting organization, an organization must meet one of three relationship tests:

    Test 1: “Operated, supervised, or controlled by” one or more publicly supported organizations, or

    Test 2: “Supervised or controlled in connection with” one or more publicly supported organizations, or

    Test 3: “Operated in connection with” one or more publicly supported organizations.

  • 1 - Information to establish the “operated, supervised, or controlled by” relationship (Test 1) Is a majority of your governing board or officers elected or appointed by the supported organization(s)? If “Yes,” describe the process by which your governing board is appointed and elected; go to Section III. If “No,” continue to line 2.

  • 2 - Information to establish the “supervised or controlled in connection with” relationship (Test 2)

    Does a majority of your governing board consist of individuals who also serve on the governing board of the supported organization(s)? If “Yes,” describe the process by which your governing board is appointed and elected; go to Section III. If “No,” go to line 3.

  • 3 - Information to establish the “operated in connection with” responsiveness test (Test 3)

    Are you a trust from which the named supported organization(s) can enforce and compel an accounting under state law? 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 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 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 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 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,” explain and go to Section III. If “No,” continue to line 6a.

  • 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 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 activity? If “Yes,” explain.

  • 7a - Does your organizing document specify the supported organization(s) by name? If “Yes,” state the article and paragraph number and go to Section III. If “No,” answer line 7b.

  • b - Attach a statement describing whether there has been an historic and continuing relationship between you and the supported organization(s).

  • Section III

  • Organizational Test

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

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

  • 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 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 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 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.

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

  • Schedule E is intended to determine whether you are eligible for tax exemption under section 501(c)(3) from the postmark date of your application or from your date of incorporation or formation, whichever is earlier. If you are not eligible for tax exemption under section 501(c)(3) from your date of incorporation or formation, Schedule E is also intended to determine whether you are eligible for tax exemption under section 501(c)(4) for the period between your date of incorporation or formation and the postmark date of your application.

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

  • 2a - Are you a public charity with annual gross receipts that are normally $5,000 or less? If “Yes,” stop here. Answer “No” if you are a private foundation, regardless of your gross receipts.

  • b - If your gross receipts were normally more than $5,000, are you filing this application within 90 days from the end of the tax year in which your gross receipts were normally more than $5,000? If “Yes,” stop here.

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

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

  • c - If you were included as a subordinate in a timely filed group exemption request that was denied, are you filing this application within 27 months from the postmark date of the Internal Revenue Service final adverse ruling letter? If “Yes,” stop here.

  • 4 - Were you created on or before October 9, 1969? If “Yes,” stop here. Do not complete the remainder of this schedule.

  • 5 - If you answered “No” to lines 1 through 4, we cannot recognize you as tax exempt from your date of formation unless you qualify for an extension of time to apply for exemption. Do you wish to request an extension of time to apply to be recognized as exempt from the date you were formed? If “Yes,” attach a statement explaining why you did not file this application within the 27-month period. Do not answer lines 6, 7, or 8. If “No,” go to line 6a.

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

  • Note. Be sure your ruling eligibility agrees with your answer to Part X, line 6.

    b -Do you anticipate significant changes in your sources of support in the future? If “Yes,” complete line 7 below.

  • 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.

  • 4a - 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, 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? 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,” 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.

  • 10a - Do you own the facility? If “No,” describe any enforceable rights you possess to purchase the facility in the future; go to line 10c. If “Yes,” answer line 10b.

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

  • c - Do you lease the facility or the land on which it is located? If “Yes,” describe the parties to the lease(s) and provide copies of all leases.

  • 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, infirmity, or other criteria and explain how you select persons for your housing.

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

  • 2a - Do you charge an entrance or founder’s fee? If “Yes,” describe what this charge covers, whether it is a one-time fee, how the fee is determined, whether it is payable in a lump sum or on an installment basis, whether it is refundable, and the circumstances, if any, under which it may be waived.

  • b - Do you charge periodic fees or maintenance charges? If “Yes,” describe what these charges cover and how they are determined.

  • c - Is your housing affordable to a significant segment of the elderly or handicapped persons in the community? Identify your community. Also, if “Yes,” explain how you determine your housing is affordable.

  • 3a - Do you have an established policy concerning residents who become unable to pay their regular charges? If “Yes,” describe your established policy.

  • b - Do you have any arrangements with government welfare agencies or others to absorb all or part of the cost of maintaining residents who become unable to pay their regular charges? If “Yes,” describe these arrangements.

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

  • 5 - Are your facilities designed to meet the physical, emotional, recreational, social, religious, and/or other similar needs of the elderly or handicapped? 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 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,” describe what these charges cover and how they are determined.

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

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

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