Form 1023-EZ Streamlined Application for Recognition of Exemption Und

Version A, Cycle 12

Form

1023-EZ

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

(Rev. May 2014)

OMB No. 1545-0056

a Do

Department of the Treasury
Internal Revenue Service

not enter social security numbers on this form as it may be made public.
a Information about Form 1023-EZ and its separate instructions is at www.irs.gov/form1023.

Note: If exempt status is
approved, this application will
be open for public inspection.

Check this box to attest that you have completed the Form 1023-EZ Eligibility Worksheet in the current instructions and are eligible to apply for
exemption using Form 1023-EZ.

Part I

Identification of Applicant

1a Full Name of Organization
b Address (number, street, and room/suite). If a P.O. Box, see instructions.
2

Employer Identification Number

5

Contact Telephone Number

3 Month Tax Year Ends (MM)

c City

d State

e Zip Code + 4

4 Person to Contact if More Information is Needed
6 Fax Number (optional)

7 User Fee Submitted

8 List the names, titles, and mailing addresses of your officers, directors, and/or trustees. (If you have more than five, see instructions.)
Last Name:

Title:

Street Address:

City:

State:

First Name:

Last Name:

Title:

Street Address:

INTERNAL USE ONLY
City:

First Name:

State:

Last Name:

First Name:
Street Address:
First Name:

State:

Last Name:

Title:

City:

State:

Last Name:

Title:

City:

State:

Zip Code + 4:

Zip Code + 4:

Zip Code + 4:

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Street Address:

DRAFT AS OF
April 8, 2014
City:

Zip Code + 4:

Title:

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Street Address:

Zip Code + 4:

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First Name:

9 a Organization's Website (if available):
b Organization's Email (optional):

Part II

Organizational Structure

1 To file this form, you must be a corporation, an unincorporated association, or a trust. Check the box for the type of organization.

2

Corporation
Unincorporated association
Trust
Check this box to attest that you have the organizing document necessary for the organizational structure indicated above.
(See the instructions for an explanation of necessary organizing documents.)

3 Date incorporated if a corporation, or formed if other than a corporation (MMDDYYYY):
4 State of incorporation or other formation:
5 Section 501(c)(3) requires that your organizing document must limit your purposes to one or more exempt purposes within section 501(c)(3).
Check this box to attest that your organizing document contains this limitation.
6 Section 501(c)(3) requires that your organizing document must not expressly empower you to engage, otherwise than as an insubstantial part of your
activities, in activities that in themselves are not in furtherance of one or more exempt purposes.
Check this box to attest that your organizing document does not expressly empower you to engage, otherwise than as an insubstantial
part of your activities, in activities that in themselves are not in furtherance of one or more exempt purposes.
7 Section 501(c)(3) requires that your organizing document must provide that upon dissolution, your remaining assets be used exclusively for
section 501(c)(3) exempt purposes. Depending on your entity type and the state in which you are formed, this requirement may be satisfied by
operation of state law.
Check this box to attest that your organizing document contains the dissolution provision required under section 501(c)(3) or that you do
not need an express dissolution provision in your organizing document because you rely on the operation of state law in the state in which
you are formed for your dissolution provision.

For Paperwork Reduction Act Notice, see the instructions.

Catalog No. 66267N

Form 1023-EZ (Rev. 5-2014)

Version A, Cycle 12
Page 2

Form 1023-EZ (Rev. 5-2014)

Part III

Your Specific Activities

1 Enter the appropriate 3-character NTEE Code that best describes your activities (See the instructions):
2 To qualify for exemption as a section 501(c)(3) organization, you must be organized and operated exclusively to further one or more of the
following purposes. By checking the box or boxes below, you attest that you are organized and operated exclusively to further the purposes
indicated. Check all that apply.
Charitable
Scientific

Religious
Literary

Educational
Testing for public safety

To foster national or international amateur sports competition
Prevention of cruelty to children or animals
3 To qualify for exemption as a section 501(c)(3) organization, you must:
• Refrain from supporting or opposing candidates in political campaigns in any way.
• Ensure that your net earnings do not inure in whole or in part to the benefit of private shareholders or individuals (that is, board members,
officers, key management employees, or other insiders).
• Not further non-exempt purposes (such as purposes that benefit private interests) more than insubstantially.
• Not be organized or operated for the primary purpose of conducting a trade or business that is not related to your exempt purpose(s).
• Not devote more than an insubstantial part of your activities attempting to influence legislation or, if you made a section 501(h) election, not
normally make expenditures in excess of expenditure limitations outlined in section 501(h).
• Not provide commercial-type insurance as a substantial part of your activities.
Check this box to attest that you have not conducted and will not conduct activities that violate these prohibitions and restrictions.
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Yes

No

Yes

No

Yes

No

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Yes
Yes

No
No
No

Yes

No

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4 Do you or will you attempt to influence legislation? . . . . . . . . . . .
(If yes, consider filing Form 5768. See the instructions for more details.)
5 Do you or will you pay compensation to any of your officers, directors, or trustees? .
(Refer to the instructions for a definition of compensation.)

INTERNAL USE ONLY

6 Do you or will you donate funds to or pay expenses for individual(s)? . . . . . . . . . . . . . . .
7 Do you or will you conduct activities or provide grants or other assistance to individual(s) or organization(s) outside the
United States? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8 Do you or will you engage in financial transactions (for example, loans, payments, rents, etc.) with any of your officers,
directors, or trustees, or any entities they own or control? . . . . . . . . . . . . . . . . . . .

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DRAFT AS OF
April 8, 2014

9 Do you or will you have unrelated business gross income of $1,000 or more during a tax year? .
10 Do you or will you operate bingo or other gaming activities? . . . . . . . . . . .
11 Do you or will you provide disaster relief? . . . . . . . . . . . . . . . .

Part IV

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Foundation Classification

D

Part IV 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.
1 If you qualify for public charity status, check the appropriate box (1a – 1c below) and skip to Part V below.
a

Check this box to attest that you normally receive at least one-third of your support from public sources or you normally receive at least 10
percent of your support from public sources and you have other characteristics of a publicly supported organization. Sections 509(a)(1) and
170(b)(1)(A)(vi).

b

Check this box to attest that you normally receive more than one-third of your support from a combination of gifts, grants, contributions,
membership fees, and gross receipts (from permitted sources) from activities related to your exempt functions and normally receive not more
than one-third of your support from investment income and unrelated business taxable income. Section 509(a)(2).

c

Check this box to attest that you are operated for the benefit of a college or university that is owned or operated by a governmental unit.
Sections 509(a)(1) and 170(b)(1)(A)(iv).

2 If you are not described in items 1a – 1c above, you are a private foundation. As a private foundation, you are required by section 508(e) to have
specific provisions in your organizing document, unless you rely on the operation of state law in the state in which you were formed to meet
these requirements. These specific provisions require that you operate to avoid liability for private foundation excise taxes under sections
4941-4945.
Check this box to attest that your organizing document contains the provisions required by section 508(e) or that your organizing
document does not need to include the provisions required by section 508(e) because you rely on the operation of state law in your
particular state to meet the requirements of section 508(e). (See the instructions for explanation of the section 508(e) requirements.)

Form 1023-EZ (Rev. 5-2014)

Version A, Cycle 12
Page 3

Form 1023-EZ (Rev. 5-2014)

Part V

Reinstatement After Automatic Revocation

Complete this section only if you are applying for reinstatement of exemption after being automatically revoked for failure to
file required annual returns or notices for three consecutive years, and you are applying for reinstatement under section 4 or 7
of Revenue Procedure 2014-11. (Check only one box.)
Check this box if you are seeking retroactive reinstatement under section 4 of Revenue Procedure 2014-11. By checking this box, you attest
that you meet the specified requirements of section 4, that your failure to file was not intentional, and that you have put in place procedures
to file required returns or notices in the future. (See the instructions for requirements.)
Check this box if you are seeking reinstatement under section 7 of Revenue Procedure 2014-11, effective the date you are filling this
application.

Part VI

Signature

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, and to the best of my knowledge it is true, correct, and complete.

(Type or print name of signer)

(Date)

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(Signature of Officer, Director, Trustee, or other authorized official)

F

F

PLEASE
SIGN
HERE

(Type or print title or authority of signer)

INTERNAL USE ONLY

D

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DRAFT AS OF
April 8, 2014

Form 1023-EZ (Rev. 5-2014)