Get IRS 1023 Form

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)

11

Date incorporated if a corporation, or formed, if other than a corporation.

(MM/DD/YYYY)

/

/

12

Were you formed under the laws of a foreign country?

Yes

No

If “Yes,” state the country.

For Paperwork Reduction Act Notice, see instructions.

Cat. No. 17133K

Form 1023 (Rev. 12-2017)

Form 1023 (Rev. 12-2017)

Name:

EIN:

Page 2

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 IV

Narrative Description of Your Activities

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)

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.

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)

Name:

EIN:

Page 4

Part V

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

and Independent Contractors (Continued)

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?

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.

6a

Do you or will you compensate any of your officers, directors, trustees, highest compensated employees, and highest

Yes

No

compensated independent contractors listed in lines 1a, 1b, or 1c through non-fixed payments, such as discretionary

bonuses or revenue-based payments? If “Yes,” describe all non-fixed compensation arrangements, including how the

amounts are determined, who is eligible for such arrangements, whether you place a limitation on total compensation,

and how you determine or will determine that you pay no more than reasonable compensation for services. Refer to

the instructions for Part V, lines 1a, 1b, and 1c, for information on what to include as compensation.

b

Do you or will you compensate any of your employees, other than your officers, directors, trustees, or your

Yes

No

five highest compensated employees who receive or will receive compensation of more than $50,000 per

year, through non-fixed payments, such as discretionary bonuses or revenue-based payments? If “Yes,”

describe all non-fixed compensation arrangements, including how the amounts are or will be determined, who

is or will be eligible for such arrangements, whether you place or will place a limitation on total compensation,

and how you determine or will determine that you pay no more than reasonable compensation for services.

Refer to the instructions for Part V, lines 1a, 1b, and 1c, for information on what to include as compensation.

7a

Do you or will you purchase any goods, services, or assets from any of your officers, directors, trustees, highest

Yes

No

compensated employees, or highest compensated independent contractors listed in lines 1a, 1b, or 1c? If “Yes,”

describe any such purchase that you made or intend to make, from whom you make or will make such purchases, how

the terms are or will be negotiated at arm’s length, and explain how you determine or will determine that you pay no

more than fair market value. Attach copies of any written contracts or other agreements relating to such purchases.

b

Do you or will you sell any goods, services, or assets to any of your officers, directors, trustees, highest

Yes

No

compensated employees, or highest compensated independent contractors listed in lines 1a, 1b, or 1c? If “Yes,”

describe any such sales that you made or intend to make, to whom you make or will make such sales, how the

terms are or will be negotiated at arm’s length, and explain how you determine or will determine you are or will be

paid at least fair market value. Attach copies of any written contracts or other agreements relating to such sales.

8a

Do you or will you have any leases, contracts, loans, or other agreements with your officers, directors,

Yes

No

trustees, highest compensated employees, or highest compensated independent contractors listed in

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

Yes

No

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)

Part VI

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

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

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

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.

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

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.

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

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.

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.

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

Yes

No

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.

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

Yes

No

(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.

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.

Form 1023 (Rev. 12-2017)

Name:

EIN:

Page 9

Part IX

Financial Data

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.

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?