1023-EZ Streamlined Application for Recognition of Exemption

Form

1023-EZ

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

(Rev. January 2018)

OMB No. 1545-0056
Note: If exempt status is approved,
this application will be open for
public inspection.

Do not enter Social Security numbers on this form as it will be made public.

Department of the Treasury
Internal Revenue Service

Information about Form 1023-EZ and its separate instructions is at www.irs.gov/form1023

Check this box to attest that you have completed the Form 1023-EZ Eligibility Worksheet in the current instructions, are eligible to apply for exemption
using Form 1023-EZ, and have read and understand the requirements to be exempt under section 501(c)(3).
Have your annual gross receipts exceeded $50,000 in any of the past 3 years and/or do you project that your annual gross receipts will exceed
$50,000 in any of the next 3 years? If yes, stop. Do not file Form 1023-EZ. See Instructions.
Do you have total assets the fair market value of which is in excess of $250,000? If yes, stop. Do not file Form 1023-EZ. See Instructions.

Part I
1a

2

Employer Identification Number

5

Contact Telephone Number

8

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

3 Month Tax Year Ends (MM)

d State

State:

Last Name:

Street Address:

State:

Last Name:

Street Address:

State:

Last Name:

Street Address:

Zip code + 4:

Title:
City:

First Name:

Zip code + 4:

Title:
City:

First Name:

Zip code + 4:

Title:
City:

First Name:

7 User Fee Submitted

State:

Last Name:

Street Address:

e Zip code + 4

Title:
City:

First Name:

Zip code + 4:

Title:
City:

State:

Zip code + 4:

Organization's Website (if available):
Organization's Email (optional):

Organizational Structure
To file this form, you must be a corporation, an unincorporated association, or a trust. Select the box for the type of organization.
Corporation

2

No

4 Person to Contact if More Information is Needed

Last Name:

Street Address:

1

c City

6 Fax Number (optional)

First Name:

b

Yes

Identification of Applicant

Mailing Address (number, street, and room/suite). If a P.O. box, see instructions.

Part II

No

Full Name of Organization

b

9a

Yes

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.1-2018)

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Form 1023-EZ (Rev. 1-2018)

Part III

Your Specific Activities

1 Briefly describe the organization's mission or most significant activities (limit 250 characters)

2 Enter the appropriate 3-character NTEE Code that best describes your activities (See the instructions):
3 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

Religious

Educational

Scientific

Literary

Testing for public safety

To foster national or international amateur sports competition

Prevention of cruelty to children or animals

4 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.
5 Do you or will you attempt to influence legislation?
(If yes, consider filing Form 5768. See the instructions for more details.)

Yes

No

6 Do you or will you pay compensation to any of your officers, directors, or trustees?
(Refer to the instructions for a definition of compensation.)

Yes

No

7 Do you or will you donate funds to or pay expenses for individual(s)?

Yes

No

8 Do you or will you conduct activities or provide grants or other assistance to individual(s) or organization(s) outside the United
States?

Yes

No

9 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?

Yes

No

10 Do you or will you have unrelated business gross income of $1,000 or more during a tax year?

Yes

No

11 Do you or will you operate bingo or other gaming activities?

Yes

No

12 Do you or will you provide disaster relief?

Yes

No

Part IV

Foundation Classification

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 Are you applying for recognition as a church, school, or hospital (described in section 170(b)(1)(A)(i), (ii), or (iii) of the Internal
Revenue Code)? If yes, stop. Do not file Form 1023-EZ. See Instructions

Yes

No

2 If you qualify for public charity status, check the appropriate box (2a - 2c below) and skip to Part V below.
a

Select 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

Select 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

Select 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).

3 If you are not described in items 2a - 2c 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.
Select 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. 1-2018)

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Form 1023-EZ (Rev. 1-2018)

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.)
1

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.)

2

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 name of signer)

(Type title or authority of signer)

(Date)

Form 1023-EZ (Rev. 1-2018)