1023 Application for Recognition of Exemption Under Section 5

U.S. Tax-Exempt Income Tax Return

f1023--2020

OMB: 1545-0047

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Form

1023

(Rev. January 2020)
Department of the Treasury
Internal Revenue Service

OMB No. 1545-0047

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

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 may be made public.
Go to www.irs.gov/Form1023 for instructions and the latest information.

Use the "?" buttons throughout this form for help in completing this application. For additional help, call IRS Exempt Organizations Customer Account
Services toll-free at 1-877-829-5500.
If you cannot complete required responses within the textbox limits throughout this form, upload your additional narratives with the other required
documents.
Part I
Identification of Applicant
1a Full Name of Organization (exactly as it appears in your organizing document)
c Mailing Address (Number, street and room/suite)
f State

b Care of Name (if applicable)

d City

e Country

g Zip Code + 4

h Foreign Province (or State)

Employer Identification Number

3 Month Tax Year Ends

Contact Telephone Number

Organization's Website (if available):

List the names, titles, and mailing addresses of your officers, directors, and/or trustees.

First Name:

Zip Code (or Foreign Postal Code):

Zip Code (or Foreign Postal Code):
Last Name:

Mailing Address:

Title:
City:

State (or Province):

Zip Code (or Foreign Postal Code):
Last Name:

Mailing Address:

Title:
City:

State (or Province):
First Name:

Title:
City:

State (or Province):

First Name:

User Fee Submitted

Title:

Last Name:

Mailing Address:
First Name:

Fax Number (optional)

City:

State (or Province):
First Name:

4 Person to Contact if More Information is Needed (officer,
director, trustee, or authorized representative)

Last Name:

Mailing Address:

i Foreign Postal Code

Zip Code (or Foreign Postal Code):
Last Name:

Mailing Address:
State (or Province):

Title:
City:
Zip Code (or Foreign Postal Code):

Check here to add more officers, directors, and/or trustees.

For Paperwork Reduction Act Notice, see instructions.

Cat. No. 17133K

Form 1023 (Rev. 01-2020)

Part II
1

Name:

Page 2

EIN:

Organizational Structure

You must be a corporation, limited liability company (LLC), unincorporated association, or trust to be tax exempt.
Select your type of organization.
Corporation
At the end of this form, you must upload a copy of your articles of incorporation (and any amendments) that shows proof of filing with the
appropriate state agency.
Limited Liability Company (LLC)
At the end of this form, you must upload a copy of your articles of organization (and any amendments) that shows proof of filing with the
appropriate state agency. Also, if you adopted an operating agreement, upload a copy, along with any amendments.
Unincorporated Association
At the end of this form, you must upload a copy of your articles of association, constitution, or other similar organizing document that is dated and
includes at least two signatures. Include signed and dated copies of any amendments.
Trust
At the end of this form, you must upload a signed and dated copy of your trust agreement. Include signed and dated copies of any amendments.

Enter the date you formed. (MM/DD/YYYY)

Select your state (or U.S. territory) of incorporation or other formation. If you were formed under the laws of a
foreign country, select Foreign Country.

Have you adopted bylaws? If "Yes," at the end of this form, upload a current copy showing the date of adoption. If "No,"
explain how you select your officers, directors, or trustees.

5 Are you a successor to another organization?

Yes

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 nonprofit status. If "Yes," complete Schedule G.

Form 1023 (Rev. 01-2020)

Part III

Name:

Page 3

EIN:

Required Provisions in Your Organizing Document

Part III helps ensure that, when you submit this application, your organizing document contains the required provisions to meet the organizational test
under section 501(c)(3).
If you cannot check "Yes" in both Lines 1 and 2, your organizing document does not meet the organizational test. DO NOT file this application until you
have amended your organizing document. Remember to upload your original and amended organizing documents at the end of this form.
1

Section 501(c)(3) requires that your organizing document limit your purposes to one or more exempt purposes within section 501(c)(3), such as
charitable, religious, educational, and/or scientific purposes.
The following is an example of an acceptable purpose clause: The organization is organized exclusively for charitable, religious, educational, and scientific
purposes under section 501(c)(3) of the Internal Revenue Code, or corresponding section of any future federal tax code.
Does your organizing document meet this requirement?

Yes

1a State specifically where your organizing document meets this requirement, such as a reference to a particular article or section in your organizing
document (Page/Article/Paragraph):

Section 501(c)(3) requires that your organizing document provide that upon dissolution, your remaining assets be used exclusively for section 501(c)
(3) exempt purposes, such as charitable, religious, educational, and/or scientific purposes. Depending on your entity type and the state in which you
are formed, this requirement may be satisfied by operation of state law.
The following is an example of an acceptable dissolution clause: Upon the dissolution of this organization, assets shall be distributed for one or more exempt
purposes within the meaning of section 501(c)(3) of the Internal Revenue Code, or corresponding section of any future federal tax code, or shall be distributed
to the federal government, or to a state or local government, for a public purpose.
Does your organizing document meet this requirement?

Yes

2a State specifically where your organizing document meets this requirement, such as a reference to a particular article or section in your organizing
document (Page/Article/Paragraph) or indicate that you rely on state law.

Form 1023 (Rev. 01-2020)

Name:

EIN:

Page 4

Part IV
Your Activities
1 Describe completely and in detail your past, present, and planned activities. Do not refer to or repeat the purposes in your organizing document.
For each past, present, or planned activity, include information that answers the following questions:
a.
b.
c.
d.
e.
f.

What is the activity?
Who conducts the activity?
Where is the activity conducted?
What percentage of your total time is allocated to the activity?
How is the activity funded (for example, donations, fees, etc.) and what percentage of your overall expenses is allocated to this activity?
How does the activity further your exempt purposes?

Form 1023 (Rev. 01-2020)

Part IV
2

Name:

Page 5

EIN:

Your Activities (continued)

Enter the 3-character NTEE Code that best describes your activities.
Or check here if you want the IRS to select the NTEE Code that best describes your activities.

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.

Yes

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? If "Yes," explain how these related individuals are eligible for goods, services, or funds.

Yes

Do you or will you support or oppose candidates in political campaigns in any way? If "Yes," explain.

Yes

Do you or will you attempt to influence legislation? If "Yes," explain how you attempt to influence legislation.

Yes

Form 1023 (Rev. 01-2020)

Part IV

Name:

Page 6

EIN:

Your Activities (continued)

6a Did you or will you make an election to have your legislative activities measured by expenditures by filing Form 5768? 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.

Yes

Do you or will you publish, own, or have rights in music, literature, tapes, artworks, choreography, scientific discoveries, or
other intellectual property? If "Yes," 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.

Yes

Do you or will you provide educational information to the general public on budgeting, personal finance, financial literacy,
saving and spending practices, the sound use of consumer credit, and/or assist individuals and families with financial
problems such as credit card debt and foreclosure by providing them with counseling? If "Yes," explain.

Yes

Do you or will you make grants, loans, or other distributions to organizations? If "Yes," describe the type and purpose of the
grants, loans, or distributions, how you select your recipients including submission requirements (such as grant proposals or
application forms), and the criteria you use or will use to select recipients. Also describe how you ensure the grants, loans,
and other distributions are or will be used for their intended purposes (including whether you require periodic or final
reports on the use of funds and any procedures you have if you identify that funds are not being used for their intended
purposes). Finally, describe the records you keep with respect to grants, loans, or other distributions you make and identify
any recipient organizations and any relationships between you and the recipients. If "No," continue to Line 10.

Yes

Form 1023 (Rev. 01-2020)

Part IV

Name:

Page 7

EIN:

Your Activities (continued)

9a Do you or will you make grants, loans, or other distributions to organizations that are not recognized by the IRS as tax
exempt under section 501(c)(3)? If "Yes," name and/or describe the non-section 501(c)(3) organizations to whom you do or
will make distributions and explain how these distributions further your exempt purposes.

Yes

9b Do you or will you make grants, loans, or other distributions to foreign organizations? If "Yes," name each foreign
organization (if not already provided), the country and region within each country in which each foreign organization
operates, any relationship you have with each foreign organization, and whether the foreign organization accepts
contributions earmarked for a specific country or organization (if so, specify which countries or organizations). If "No,"
continue to Line 10.

Yes

9c 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.

Yes

9d 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.

Yes

9e 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 periodic reporting requirements,
auditing grantees, site visits by your employees or compliance checks by impartial experts, etc., to verify that grant funds are
being used appropriately.

Yes

Form 1023 (Rev. 01-2020)

Part IV

Name:

Page 8

EIN:

Your Activities (continued)

9f Do you share board members or other key personnel with the recipient organization(s)? If "Yes," identify the relationships.

Yes

9g When you make grants, loans, or other distributions to foreign organizations, will you check the OFAC List of Specially
Designated Nationals and Blocked Persons for names of individuals and entities with whom you are dealing to determine if
they are included on the list? Describe any other practices you will engage in to ensure that foreign expenditures or grants
are not diverted to support terrorism or other non-charitable activities.

Yes

9h Will you comply with all United States statutes, executive orders, and regulations that restrict or prohibit U.S. persons from
engaging in transactions and dealings with designated countries, entities, or individuals, or otherwise engaging in activities
in violation of economic sanctions administered by OFAC?

Yes

9i Will you acquire from OFAC the appropriate license and registration where necessary?

Yes

10 Do you or will you operate in a foreign country or countries? If "Yes," name each foreign country and region within each
country in which you do or will operate and describe your operations in each one. If "No," continue to Line 11.

Yes

10a When you conduct activities in foreign countries, will you check the OFAC List of Specially Designated Nationals and
Blocked Persons for names of individuals and entities with whom you are dealing to determine if they are included on the
list? Describe any other practices you will engage in to ensure that foreign expenditures or grants are not diverted to
support terrorism or other non-charitable activities.

Yes

10b Will you comply with all United States statutes, executive orders, and regulations that restrict or prohibit U.S. persons from
engaging in transactions and dealings with designated countries, entities, or individuals, or otherwise engaging in activities
in violation of economic sanctions administered by OFAC?

Yes

10c Will you acquire from OFAC the appropriate license and registration where necessary?

Yes

Form 1023 (Rev. 01-2020)

Part IV

Page 9

EIN:

Name:

Your Activities (continued)

11 Are you a sponsoring organization that maintains one or more donor advised funds? If yes, please provide a complete
description of your program, including the specific advice that such donors may provide. Describe in detail the control you
maintain (or will maintain) over the use of the funds.

Yes

12 Do you or will you operate a school?
If "Yes," complete Schedule B.

Yes

13 Is your principal purpose or function to provide hospital or medical care?
If "Yes," complete Schedule C.

Yes

14 Do you or will you provide low-income housing?
If "Yes," complete Schedule F.

Yes

15 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 - Section I.

Yes

16 Check any of the following fundraising activities that you will undertake (check all that apply):
Website, mail, email, personal, and/or phone solicitations

Foundation grant solicitations

Receive donations from another organization's website

Government grant solicitations

Bingo

Other (non-bingo) gaming activities

Other (describe)

We will not engage in fundraising activities.
17 Do you or will you engage in fundraising activities for other organizations? If "Yes," describe these arrangements, including
the names or descriptions of the organizations for which you raise funds.

Form 1023 (Rev. 01-2020)

Part V
1

Name:

Page 10

EIN:

Compensation and Other Financial Arrangements

Do you or will you compensate officers, directors, or trustees, or do or will you have highest compensated employees, or
highest compensated independent contractors? If "No," continue to Line 2.

Yes

In establishing compensation for your officers, directors, trustees, highest compensated employees, and highest compensated independent contractors:
1a Do or will the individuals that approve compensation arrangements follow a conflict of interest policy?

Yes

1b Do or will you approve compensation arrangements in advance of paying compensation?

Yes

1c Do or will you document in writing the date and terms of approved compensation arrangements?

Yes

1d Do or will you record in writing the decision made by each individual who decided or voted on compensation arrangements?

Yes

1e Do 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?

Yes

1f Do or will you record in writing both the information on which you relied to base your decision and its source?

Yes

1g Do or will you have any other practices you use to set reasonable compensation? If "Yes," describe these practices.

Yes

Have you adopted a conflict of interest policy consistent with the sample conflict of interest policy in Appendix A to the
instructions? If you are a hospital, answer "Yes" if your conflict of interest policy includes provisions consistent with the
additional healthcare related provisions in the sample document. If "No," describe the procedures you will follow to ensure
that persons who have a conflict of interest will not have influence over setting their own compensation or regarding
business deals with themselves.

Yes

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

Yes

Form 1023 (Rev. 01-2020)

Part V

Name:

Page 11

EIN:

Compensation and Other Financial Arrangements (continued)

Do you or will you purchase or sell any goods, services, or assets from or to: (i) any of your officers, directors, or trustees; (ii)
any family of any of your officers, directors, or trustees; (iii) any organizations in 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; (iv) your highest compensated employees; or (v) your highest compensated independent contractors? If "Yes,"
describe any such transactions that you made or intend to make, with whom you make or will make such transactions, how
the terms are or will be negotiated at arm's length, and how you determine you pay no more than fair market value or you
are paid at least fair market value.

Yes

Do you or will you have any leases, contracts, loans, or other agreements with: (i) your officers, directors, or trustees; (ii) any
family of any of your officers, directors, or trustees; (iii) any organizations in 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;
(iv) your highest compensated employees; or (v) your highest compensated independent contractors? If "Yes," describe any
written or oral arrangements that you made or intend to make, with whom you have or will have such arrangements, how
the terms are or will be negotiated at arm's length, and how you determine you pay no more than fair market value or you
are paid at least fair market value.

Yes

Do you or will you contract with another organization to develop, build, market, or finance your facilities?
If "Yes," describe each facility, the role of the other organization, and any business or family relationship between the
organization and your officers, directors, or trustees. Explain how that entity is selected, how the terms of any contract(s) are
negotiated at arm's length, and how you determine you will pay no more than fair market value for services.

Yes

Form 1023 (Rev. 01-2020)

Part V

Name:

Page 12

EIN:

Compensation and Other Financial Arrangements (continued)

Does or will someone other than your own employees or volunteers manage your activities or facilities?
If "Yes," describe the activities or facilities that will be managed by others, the names of the persons or organizations that
manage or will manage your activities or facilities, and any business or family relationship between the organization and your
officers, directors, or trustees. Explain how these managers were or will be selected, how the terms of any contracts or other
agreements were or will be negotiated, and how you determine you will pay no more than fair market value for services.

Yes

Do you participate in any joint ventures, including partnerships or limited liability companies treated as partnerships, in
which you share profits and losses with partners? 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.

Yes

Part VI
1

Financial Data

Select the option that best describes you to determine the years of revenues and expenses you need to provide.
You completed less than one tax year.
Provide a total of three years of financial information (including the current year and two future years of reasonable and good faith projections
of your future finances) in the following Statement of Revenues and Expenses.
You completed at least one tax year but fewer than five.
Provide a total of four years financial information (including the current year and three years of actual financial information or reasonable and
good faith projections of your future finances) in the following Statement of Revenues and Expenses.
You completed five or more tax years.
Provide financial information for your five most recent tax years (including the current year) in the following Statement of Revenues and
Expenses.

Form 1023 (Rev. 01-2020)

Part VI

Page 13

EIN:

Name:

Financial Data (continued)
A. Statement of Revenues and Expenses
Type of revenue

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

Membership fees received

Gross investment income

Net unrelated business income

Taxes levied for your benefit

Value of services or facilities furnished by a
governmental unit without charge (not including
the value of services generally furnished to the
public without charge)

Any revenue not otherwise listed above or in lines 9 12 below (provide an itemized list below)

Total of lines 1 through 7

Gross receipts from admissions, merchandise sold or
services performed, or furnishing of facilities in any
activity that is related to your exempt purposes
(provide an itemized list below)

Current tax year

4 prior tax years or 2 succeeding tax years

From:

To:

10 Total of lines 8 and 9
11 Net gain or loss on sale of capital assets (provide an
itemized list below)
12 Unusual grants (provide an itemized list below)
13 Total Revenue (add lines 10 through 12)
Type of expense

Current tax year

4 prior tax years or 2 succeeding tax years

14 Fundraising expenses
Contributions, gifts, grants, and similar amounts
15 paid out (provide an itemized list below)
16

Disbursements to or for the benefit of members
(provide an itemized list below)

17 Compensation of officers, directors, and trustees
18 Other salaries and wages
19 Interest expense
20 Occupancy (rent, utilities, etc.)
21 Depreciation and depletion
22 Professional fees
23

Any expense not otherwise classified, such as
program services (provide an itemized list below)

24 Total Expenses (add lines 14 through 23)
25 Itemized financial data

Form 1023 (Rev. 01-2020)

Part VI

Page 14

EIN:

Name:

Financial Data (continued)
B. Balance Sheet (for your most recently completed tax year)

Year End:

Assets
1

Cash

Accounts receivable, net

Inventories

Bonds and notes receivable (provide an itemized list below)

Corporate stocks (provide an itemized list below)

Loans receivable (provide an itemized list below)

Other investments (provide an itemized list below)

Depreciable assets (provide an itemized list below)

Land

10 Other assets (provide an itemized list below)
11 Total Assets (add lines 1 through 10)
Liabilities
12 Accounts payable
13 Contributions, gifts, grants, etc. payable
14 Mortgages and notes payable (provide an itemized list below)
15 Other liabilities (provide an itemized list below)
16 Total Liabilities (add lines 12 through 15)
Fund Balances or Net Assets
17 Total fund balances or net assets
18 Total Liabilities and Fund Balances or Net Assets (add lines 16 and 17)
19 Itemized financial data

Form 1023 (Rev. 01-2020)

Part VII

Name:

Page 15

EIN:

Foundation Classification

Part VII is designed to classify you as an organization that is either a private foundation or a public charity. Public charity classification is a more favorable
tax status than private foundation classification. If you are a private foundation, this part will further determine whether you are a private operating
foundation.
1

Select the foundation classification you are requesting from the list below.
You are described in 509(a)(1) and 170(b)(1)(A)(vi) as 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.
You are described in 509(a)(2) as 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).
You are described in 509(a)(1) and 170(b)(1)(A)(i) as a church or a convention or association of churches. Complete Schedule A.
You are described in 509(a)(1) and 170(b)(1)(A)(ii) as a school. Complete Schedule B.
You are described in 509(a)(1) and 170(b)(1)(A)(iii) as a hospital, a cooperative hospital service organization, or a medical
research organization operated in conjunction with a hospital. Complete Schedule C.
You are described in 509(a)(1) and 170(b)(1)(A)(iv) as an organization operated for the benefit of a college or university that is
owned or operated by a governmental unit.
You are described in 509(a)(1) and 170(b)(1)(A)(ix) as an agricultural research organization directly engaged in the continuous
active conduct of agricultural research in conjunction with a college or university.
You are described in 509(a)(3) as an organization supporting either one or more organizations described in 509(a)(1) or 509(a)
(2) or a publicly supported section 501(c)(4), (5), or (6) organization. Complete Schedule D.
You are described in 509(a)(4) as an organization organized and operated exclusively for testing for public safety.
You are a publicly supported organization and would like the IRS to decide your correct classification.
You are a private foundation.

1a 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 this box to confirm that your organizing document includes these
provisions or you rely on state law.
State specifically where your organizing document meets this requirement, such as a reference to a particular article or section in your
organizing document (Page/Article/Paragraph) or state that you rely on state law.

1b 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 - Section II.

Yes

1c Are you a private operating foundation?

Yes

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.

Form 1023 (Rev. 01-2020)

Part VII

Name:

Page 16

EIN:

Foundation Classification (continued)

1d Describe how you meet the requirements for private operating foundation status, including how you meet the income test and either the assets test,
the endowment test, or the support test. If you've been in existence for less than one year, describe how you are likely to satisfy the requirements for
private operating foundation status.

If you have been in existence more than 5 years, you must confirm your public support status. To confirm your qualification as a public charity
described in 509(a)(1) and 170(b)(1)(A)(vi) in existence for five or more tax years, you must have received one-third or more of your total support from
governmental agencies, contributions from the general public, and contributions or grants from other public charities; or 10% or more of your total
support from governmental agencies, contributions from the general public, and contributions or grants from other public charities and the facts and
circumstances indicate you are a publicly supported organization. Calculate whether you meet this support test for your most recent five-year period.
i.

Did you receive contributions from any person, company, or organization whose gifts totaled more than the 2% amount
of line 8 in Part VI-A?

Yes

If "Yes," identify each person, company, or organization by letter (A, B, C, etc.) and indicate the amount contributed by each. Keep a list
showing the name of and amount contributed by each of these donors for your records.

ii. Based on your calculations, did you receive at least one-third of your support from public sources or did you normally
receive at least 10 percent of your support from public sources and you have other characteristics of a publicly
supported organization?

Yes

2a If you have been in existence more than 5 years, you must confirm your public support status. To confirm your qualification as a public charity
described in 509(a)(2) in existence for five or more tax years, you must have normally received more than one-third of your support from
contributions, membership fees, and gross receipts from activities related to your exempt functions, or a combination of these sources, and not more
than one-third of your support from gross investment income and net unrelated business income. Calculate whether you meet this support test for
your most recent five-year period.
i.

Did you receive amounts from any disqualified persons?

Yes

If "Yes," identify each disqualified person by letter (A, B, C, etc.) and indicate the amount contributed by each. Keep a list
showing the name of and amount contributed by each of these donors for your records.

ii. Did you receive amounts from individuals or organizations other than disqualified persons that exceeded the greater of
$5,000 or 1% of the amount on line 10 of Part VI-A Statement of Revenues and Expenses?

Yes

If "Yes," identify each individual or organization by letter (A, B, C, etc.) and indicate the amount contributed by each. Keep a list
showing the name of and amount contributed by each of these donors for your records.

iii. Based on your calculations, did 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?

Form 1023 (Rev. 01-2020)

Part VIII

Page 17

EIN:

Name:

Effective Date

In general, a determination letter recognizing exemption of an organization described in section 501(c)(3) is effective as of the date of formation of an
organization if: (1) its purposes and activities prior to the date of the determination letter have been consistent with the requirements for exemption; and
(2) it has filed an application for recognition of exemption within 27 months from the end of the month in which it was organized.
1

Yes

Are you submitting this application within 27 months of the end of the month in which you were legally formed?

If "No," complete Schedule E.
Part IX

Annual Filing Requirements

If you fail to file a required information return or notice for three consecutive years, your exempt status will be automatically revoked.
1

Yes

Certain organizations are not required to file annual information returns or notices (Form 990, Form 990-EZ, or Form 990-N,
e-Postcard). If you are granted tax-exemption, are you claiming to be excused from filing Form 990, Form 990-EZ, or Form
990-N?

If "Yes," are you claiming you are excepted from filing because you are:
A church or association of churches
An integrated auxiliary (such as a men's or women's organization, religious school, mission society, or religious group)
A church-affiliated organization (other than a section 509(a)(3) organization) that is exclusively engaged in managing funds or
maintaining retirement programs and is described in Revenue Procedure 96-10, 1996-1 C.B. 577
A school below college level affiliated with a church or operated by a religious order
A mission society (other than a section 509(a)(3) supporting organization) sponsored by, or affiliated with, one or more
churches or church denominations, if more than half of the society's activities are conducted in, or directed at, persons in
foreign countries
An affiliate of a governmental unit that meets the requirements of Revenue Procedure 95-48, 1995-2 C.B. 418 (other than a
section 509(a)(3) supporting organization)
Other (describe)

Part X

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 (Rev. 01-2020)

Name:

EIN:

Page 18

Upload checklist:
Organizing document (and any amendments)
Bylaws, if adopted
Form 2848, Power of Attorney and Declaration of Representative (if applicable)
Form 8821, Tax Information Authorization (if applicable)
Supplemental responses (if applicable)
Expedited handling request (if applicable)

Form 1023 (Rev. 01-2020)

Page 19

EIN:

Name:

Schedule A. Churches
1

Do you have a written creed, statement of faith, or summary of beliefs? If "Yes," describe your written creed, statement of
faith, or summary of beliefs.

Yes

Do you have a literature of your own? If "Yes," describe your literature.

Yes

Do you have a formal code of doctrine and discipline? If "Yes," describe your code of doctrine and discipline.

Yes

Describe your religious hierarchy or ecclesiastical government.

Are you part of a group of churches with similar beliefs and structures? If "Yes," explain.

Yes

Do you have a form of worship? If "Yes," describe your form of worship.

Yes

Do you have regularly scheduled religious services? If "Yes," describe the nature of the services.

Yes

7a What is the average attendance at your regularly scheduled religious services?
8

Do you have an established place of worship? If "Yes," describe your established place of worship or where you meet to hold
regularly scheduled religious services.

Form 1023 (Rev. 01-2020)

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EIN:

Name:

Schedule A. Churches (continued)
Yes

9b Do you have a process by which an individual becomes a member? If "Yes," describe the process.

Yes

9c Do your members have voting rights, rights to participate in religious functions, or other rights? If "Yes," describe the rights
your members have.

Yes

9d May your members be associated with another denomination or church?

Yes

9e Are all of your members part of the same family?

Yes

10 Do you conduct baptisms, weddings, funerals, or other religious rites?

Yes

11 Do you have a school for the religious instruction of the young?

Yes

12 Do you have ministers or religious leaders? If "Yes," describe these roles and explain whether the ministers or religious
leaders are ordained, commissioned, or licensed after a prescribed course of study.

Yes

13 Do you have schools for the preparation of your ordained ministers or religious leaders?

Yes

14 Do you ordain, commission, or license ministers or religious leaders? If "Yes," describe the requirements for ordination,
commission, or licensure.

Yes

15 Do you have other information you believe should be considered regarding your status as a church? If "Yes," explain.

Yes

Do you have an established congregation or other regular membership group? If "No," continue to Line 10.

9a How many members do you have?

Form 1023 (Rev. 01-2020)

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EIN:

Name:

Schedule B. Schools, Colleges, and Universities
1

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?

Yes

Is the primary function of your school the presentation of formal instruction? If "No," continue to Line 3.

Yes

2a Select the best description(s) of your school:
Elementary school
Secondary school
Charter school
College or university
Technical school
Other school (describe)
3

Are you a public school because you are operated by a state or subdivision of a state or operated wholly or predominantly
from government funds or property? If "Yes," explain how you are operated by a state or subdivision of a state. Do not
complete the remainder of Schedule B.

Yes

Were you formed or substantially expanded at the time of public school desegregation in the school district or county in
which you are located?

Yes

Has a state or federal administrative agency or judicial body ever determined that you are racially discriminatory? If "Yes,"
explain.

Yes

Has your right to receive financial aid or assistance from a governmental agency ever been revoked or suspended? If "Yes,"
explain.

Yes

Have you adopted a racially nondiscriminatory policy as to students in your organizing document, bylaws, or by resolution of
your governing body?

Yes

Information Required by Revenue Procedure 75-50 as Modified by Revenue Procedure 2019-22

State where the policy is located or if adopted by resolution of your governing body.

Do your brochures, application forms, advertisements, and catalogues dealing with student admissions, programs, and
scholarships contain a statement of your racially nondiscriminatory policy? If "Yes," continue to Line 9.
By checking this box, you agree that all future printed materials, including website content, will contain the required
nondiscriminatory policy statement.

Form 1023 (Rev. 01-2020)

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EIN:

Name:

Schedule B. Schools, Colleges, and Universities (continued)
9

Have you made your racially nondiscriminatory policy known to all segments of the general community you serve by: a)
publishing a notice of your policy in a newspaper of general circulation that serves all racial segments of the community; b)
publicizing your policy over broadcast media in a way that is reasonably expected to be effective; or c) displaying a notice of
your policy at all times on your primary, publicly accessible internet home page in a manner reasonably expected to be
noticed by visitors to the homepage? If "Yes," continue to Line 10.

Yes

By checking this box, you agree that you will publicize your nondiscriminatory policy in a way that meets the requirements of
Revenue Procedure 75-50, 1975-2 C.B. 587, as modified by Revenue Procedure 2019-22, I.R.B. 1260.

10 Do or will you (or any department or division of your organization) 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.

11 Complete the table below to show the racial composition for the current academic year and projected for the next academic year. If you are not
operational, submit an estimate based on the best information available (such as the racial composition of the community you serve).
For each racial category, enter the number of (a) students, (b) faculty, and (c) administrative staff. Provide actual numbers rather than percentages for
each racial category.
Racial Category

(a) Student Body
Current Year

Next Year

(b) Faculty
Current Year

Next Year

Total
12 In the table below, enter the number and amount of loans and scholarships awarded to enrolled students by racial categories. Provide actual numbers
rather than percentages for each racial category.
Check here if you will not provide any loans or scholarships to students.
Racial Category

Number of Loans
Current Year

Next Year

Amount of Loans
Current Year

Next Year

Number of Scholarships
Current Year

Next Year

Amount of Scholarships
Current Year

Next Year

Total

Form 1023 (Rev. 01-2020)

Page 23

EIN:

Name:

Schedule B. Schools, Colleges, and Universities (continued)
13 List your incorporators, founders, board members, and donors of land or buildings, whether individuals or organizations.

14 Do any of your incorporators, founders, board members, and donors of land or buildings, whether individuals or
organizations, have an objective to maintain segregated public or private school education? If "Yes," explain.

Yes

15 Will you maintain records according to the nondiscrimination provisions contained in Revenue Procedure 75-50? If "No,"
explain.

Yes

Form 1023 (Rev. 01-2020)

Page 24

EIN:

Name:

Schedule C. Hospitals and Medical Research Organizations
1

Are you a medical research organization (an organization whose principal purpose or function is medical research and which
is directly engaged in the continuous active conduct of medical research) operated in conjunction with a hospital? If "No,"
continue to Line 2.

Yes

1a Name the hospitals with which you have a relationship and describe the relationship.

1b List your assets showing their fair market value and the portion of your assets directly devoted to medical research.

Do not complete the remainder of Schedule C.
2

Are you applying for exemption as a cooperative hospital service organization described in section 501(e)?
If "Yes," explain.

Do not complete the remainder of Schedule C.
3

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.

Form 1023 (Rev. 01-2020)

Page 25

EIN:

Name:

Schedule C. Hospitals and Medical Research Organizations (continued)
4

Do or will you provide medical services to all individuals in your community who can pay for themselves or are able to pay
through some form of insurance? If "No," explain.

Yes

Do you or will you maintain a full-time emergency room? If "Yes," continue to Line 6.

Yes

5a Are you a specialty hospital or would emergency services be duplicative based on your region or locality?

Yes

Do you provide free or below cost services? If "Yes," describe your policy for determining when and to whom you provide
these services and how these services promote the organization's benefit to the community.

Yes

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.

Yes

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.

Yes

Form 1023 (Rev. 01-2020)

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EIN:

Name:

Schedule C. Hospitals and Medical Research Organizations (continued)
9

Is your board of directors composed of a majority of individuals who are representative of the community you serve, or do
you operate under a parent organization whose board of directors is composed of a majority of individuals who are
representative of the community you serve? If "Yes," continue to Line 10.

Yes

9a List 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. If you operate under a parent organization whose
board of directors is not composed of a majority of individuals who are representative of the community you serve, provide the requested
information for your parent's board of directors as well.

10 Do you operate a facility which is required by a state to be licensed, registered, or similarly recognized as a hospital? If "No,"
do not complete the rest of Schedule C.

Yes

10a Do you conduct a community health needs assessment (CHNA) at least once every three years and adopt an implementation
strategy to meet the community health needs identified in the assessment as required by section 501(r)(3)? If "No," explain.

Yes

10b Do you have a written financial assistance policy (FAP) and a written policy relating to emergency medical care as required by
section 501(r)(4)? If "No," explain.

Yes

Form 1023 (Rev. 01-2020)

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EIN:

Name:

Schedule C. Hospitals and Medical Research Organizations (continued)
10c Do you both (1) limit amounts charged for emergency or other medically necessary care provided to individuals eligible for
assistance under your FAP to not more than amounts generally billed to individuals who have insurance covering such care,
and (2) prohibit use of gross charges as required by section 501(r)(5)? If "No," explain.

Yes

10d Do you make reasonable efforts to determine whether an individual is FAP-eligible before engaging in extraordinary
collection actions as required by section 501(r)(6)? If "No," explain.

Yes

Form 1023 (Rev. 01-2020)

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EIN:

Name:

Schedule D. Section 509(a)(3) Supporting Organizations
1

List the names, addresses, and EINs of the organizations you support.

Are all your supported organizations public charities under section 509(a)(1) or (2)? If "Yes," continue to Line 3.

2a Are your supported organizations tax exempt under section 501(c)(4), 501(c)(5), or 501(c)(6) and do your supported
organizations meet the public support test under section 509(a)(2)? If "No," explain how each organization you support is a
public charity under section 509(a)(1) or 509(a)(2).

Yes

Which of the following describes your relationship with your supported organization(s)?
A majority of your governing board or officers are elected or appointed by your supported organization(s). (Type I supporting organization)
Your control or management is vested in the same persons who control or manage your supported organization(s). (Type II supporting
organization)
One or more of your officers, directors, or trustees are elected or appointed by the officers, directors, trustees, or membership of your
supported organization(s), or one or more of your officers, directors, trustees, or other important office holders, are also members of the
governing body of your supported organization(s), or your officers, directors, or trustees maintain a close and continuous working relationship
with the officers, directors, or trustees of your supported organization(s). (Type III supporting organization)

Describe how your governing board and officers are selected. If you are a Type III organization, also describe how your officers, directors, or trustees
maintain a close and continuous working relationship with the officers, directors, or trustees of your supported organization(s).

Form 1023 (Rev. 01-2020)

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EIN:

Name:

Schedule D. Section 509(a)(3) Supporting Organizations (continued)
5

Do any persons who are disqualified persons (except individuals who are disqualified persons only because they are
foundation managers) with respect to you or persons who have a family or business relationship with any disqualified
persons 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.

Yes

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.

Yes

Does your organizing document specify your supported organization(s) by name?
If "Yes" and you selected Type I above, continue to Line 8.
If "Yes," and you selected Type II, do not complete the rest of Schedule D.
If "No" and you selected Type III above, amend your organizing document to specify your supported organization(s) by name
or you will not meet the organizational test and need to reconsider your requested public charity classification; then
continue to Line 8.

Yes

7a Does your organizing document name a similar purpose or charitable class of beneficiaries as to your supported
organization(s)? If "No," amend your organizing document to specify your supported organization(s) by name, purpose, or
class or you will not meet the organizational test and need to reconsider your requested public charity classification.
If you selected Type II above, do not complete the rest of Schedule D.
8

Do you or will you receive contributions from any person who alone, or combined with family members or an entity at least
35% controlled by that person, controls any of your supported organizations, or will you receive contributions from any
family member of, or an entity at least 35% controlled by, any person who controls any of your supported organizations? If
"Yes," explain.

If you selected Type I above, do not complete the rest of Schedule D.

Form 1023 (Rev. 01-2020)

Page 30

EIN:

Name:

Schedule D. Section 509(a)(3) Supporting Organizations (continued)
9

Do the officers, directors, or trustees of your supported organization have a significant voice in your investment policies, the
timing and making of grants, the selection of grant recipients, and in otherwise directing the use of your income or assets? If
"Yes," explain.

Yes

10 In each taxable year, do you or will you provide each of your supported organizations with (a) a written notice addressed to
a principal officer of the supported organization describing the type and amount of all of the support you provided to the
supported organization during the immediately preceding taxable year, (b) a copy of your most recently filed Form 990series return or notice, and (c) a copy of your governing documents? If 'No,' explain.

Yes

11 Do you exercise a substantial degree of direction over the policies, programs, and activities of your supported organization(s)
and appoint or elect (directly or indirectly) a majority of the officers, directors, or trustees of your supported organization(s)?
If "Yes," explain.

Yes

12 Do substantially all of your activities directly further the exempt purposes of one or more supported organizations to which
you are responsive by performing the functions of, or carrying out the purposes of, such supported organization(s) and but
for your involvement would normally be engaged in by such supported organization(s). If "Yes," explain and do not complete
the rest of Schedule D.

Yes

Form 1023 (Rev. 01-2020)

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EIN:

Name:

Schedule D. Section 509(a)(3) Supporting Organizations (continued)
13 Do you distribute at least 85% of your annual net income or 3.5% of the aggregate fair market value of all of your nonexempt-use assets (whichever is greater) to your supported organization(s)? If "No," explain.

Yes

13a How much do you contribute annually to each supported organization?

13b What is the total annual revenue of each supported organization?

13c Do you or the supported organization(s) earmark your funds for support of a particular program or activity? If "Yes," explain.

Form 1023 (Rev. 01-2020)

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Name:

Schedule E. Effective Date
1

Are you applying for reinstatement of exemption after being automatically revoked for failure to file required returns or
notices for three consecutive years? If "No," continue to Line 2.

Yes

1a Revenue Procedure 2014-11, 2014-1 C.B. 411, provides procedures for reinstating your tax-exempt status. Select the section of Revenue Procedure
2014-11 under which you want us to consider your reinstatement request.
Section 4. You are seeking retroactive reinstatement under section 4 of Revenue Procedure 2014-11. By selecting this line, 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. Do not complete the rest of Schedule E.
Section 5. You are seeking retroactive reinstatement under section 5 of Revenue Procedure 2014-11. By selecting this line, you attest that you
meet the specified requirements of section 5, that you have filed required annual returns, 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.
Describe how you exercised ordinary business care and prudence in determining and attempting to comply with your filing requirements in at
least one of the three years of revocation and the steps you have taken or will take to avoid or mitigate future failures to file timely returns or
notices. Do not complete the rest of Schedule E.
Section 6. You are seeking retroactive reinstatement under section 6 of Revenue Procedure 2014-11. By selecting this line, you attest that you
meet the specified requirements of section 6, that you have filed required annual returns, 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.
Describe how you exercised ordinary business care and prudence in determining and attempting to comply with your filing requirements in
each of the three years of revocation and the steps you have taken or will take to avoid or mitigate future failures to file timely returns or
notices. Do not complete the rest of Schedule E.
Section 7. You are seeking reinstatement under section 7 of Revenue Procedure 2014-11, effective the date you are filling this application. Do
not complete the rest of Schedule E.

Generally, if you did not file Form 1023 within 27 months of formation, the effective date of your exempt status will be the date you filed Form 1023
(submission date). Requests for an earlier effective date may be granted when there is evidence to establish you acted reasonably and in good faith
and the grant of relief will not prejudice the interests of the government.
Check this box if you accept the submission date as the effective date of your exempt status. Do not complete the rest of Schedule E.
Check this box if you are requesting an earlier effective date than the submission date.

2a Explain why you did not file Form 1023 within 27 months of formation, how you acted reasonably and in good faith, and how granting an earlier
effective date will not prejudice the interests of the Government.
You may want to include the events that led to the failure to timely file Form 1023 and to the discovery of the failure, any reliance on the advice of a
qualified tax professional and a description of the engagement and responsibilities of the professional as well as the extent to which you relied on
the professional, a comparison of (1) what your aggregate tax liability would be if you had filed this application within the 27-month period with (2)
what your aggregate liability would be if you were exempt as of your formation date, or any other information you believe will support your request
for relief.

Form 1023 (Rev. 01-2020)

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EIN:

Name:

Schedule F. Low-Income Housing
1

Describe each facility including the type of facility, whether you own or lease the facility, how many residents it can accommodate, the current
number of residents, and whether the residents purchase or rent housing from you.

Describe who qualifies for your housing in terms of income levels or other criteria and explain how you select residents.

Do you meet the safe harbor requirements outlined in Revenue Procedure 96-32, 1996-1 C.B. 717, which provides guidelines
for providing low-income housing that will be treated as charitable, including for each project that (a) at least 75 percent of
the units are occupied by residents that qualify as low-income and (b) either at least 20 percent of the units are occupied by
residents that also meet the very low-income limit for the area or 40 percent of the units are occupied by residents that also
do not exceed 120 percent of the area's very low-income limit, and less than 25 percent of the units are provided at market
rates to persons who have incomes in excess of the low-income limit?

Yes

Is your housing affordable to low-income residents? If "Yes," describe how your housing is made affordable to low-income
residents.

Yes

Do you impose any restrictions to make sure that your housing remains affordable to low-income residents? If "Yes," describe
these restrictions.

Yes

Form 1023 (Rev. 01-2020)

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EIN:

Name:

Schedule F. Low-Income Housing (continued)
6

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.

Yes

Do you provide social services to residents? If "Yes," describe these services.

Yes

Do you participate in any government housing programs? If "Yes," describe these programs.

Yes

Form 1023 (Rev. 01-2020)

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EIN:

Name:

Schedule G. Successors to Other Organizations
1

List the name, last address, and EIN of your predecessor organization and describe its activities.

List the owners, partners, principal stockholders, officers, and governing board members of your predecessor organization. Include their names,
addresses, and share/interest in the predecessor organization (if for-profit).

Are you a successor to a for-profit organization? If "Yes," explain your relationship with the predecessor organization that
resulted in your creation and explain why you took over the activities or assets of a for-profit organization or converted from
for-profit to nonprofit status; continue to Line 4.

Yes

3a Explain your relationship with the other organization that resulted in your creation and why you took over the activities or assets of another
organization.

Form 1023 (Rev. 01-2020)

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EIN:

Name:

Schedule G. Successors to Other Organizations (continued)
4

Do or will you maintain a working relationship with any of the persons listed in question 2 or with any for-profit organization
in which these persons own more than a 35% interest? If "Yes," describe the relationship.

Yes

Were any assets transferred, whether by gift or sale, from the predecessor organization to you? If "Yes," provide a list of
assets, indicate the value of each asset, explain how the value was determined, and attach an appraisal, if available. For each
asset listed, also explain if the transfer was by gift, sale, or combination thereof and describe any restrictions that were placed
on the use or sale of the assets.

Yes

Were any debts or liabilities transferred from the predecessor for-profit organization to you? If "Yes," provide a list of the
debts or liabilities that were transferred to you, indicating the amount of each, how the amount was determined, and the
name of the person to whom the debt or liability is owed.

Yes

Will you lease or rent any property or equipment to or from the predecessor organization or any persons listed in Line 2 or a
for-profit organization in which these persons own more than a 35% interest? If "Yes," describe the arrangement(s) including
how the lease or rental value was determined.

Yes

Form 1023 (Rev. 01-2020)

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Public charities and private foundations complete lines 1 through 8 of this section.

Describe the types of educational grants you provide to individuals, such as scholarships, fellowships, loans, etc., including the purpose, number and
amount(s) of grants, how the program is publicized, and if you award educational loans, the terms of the loans.

Do you maintain case histories showing recipients of your scholarships, fellowships, educational loans, or other educational
grants, including names, addresses, purposes of awards, amount of each grant, manner of selection, and relationship (if any)
to officers, trustees, or donors of funds to you? If "No," explain.

Describe the specific criteria you use to determine who is eligible for your program (for example, eligibility selection criteria could consist of
graduating high school students from a particular high school who will attend college, writers of scholarly works about American history, etc.).

Describe the specific criteria you use to select recipients (for example, specific selection criteria could consist of prior academic performance, financial
need, etc.).

Yes

Form 1023 (Rev. 01-2020)

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Describe any requirement or condition you impose on recipients to obtain, maintain, or qualify for renewal of a grant (for example, specific
requirements or conditions could consist of attendance at a four-year college, maintaining a certain grade point average, teaching in public school
after graduation from college, etc.).

Describe your procedures for supervising the scholarships, fellowships, educational loans, or other educational grants. Explain whether you obtain
reports and grade transcripts from recipients, or you pay grants directly to a school under an arrangement whereby the school will apply the grant
funds only for enrolled students who are in good standing. Also, describe your procedures for taking action if the terms of the award are violated.

How do you determine who is on the selection committee for the awards made under your program?

Are relatives of members of the selection committee, or of your officers, directors, or substantial contributors eligible for
awards made under your program? If "Yes," what measures do you take to ensure unbiased selections?

Yes

Do not complete the rest of Schedule H. If you are a private foundation, you will be directed to complete Section II of
Schedule H later in the application.

Form 1023 (Rev. 01-2020)

Name:

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Private foundations complete lines 1 through 7 of this section. Public charities do not complete this section.

As a private foundation, do you want this application to be considered as a request for advance approval of grant making
procedures?

Yes

If "No," do not complete the rest of Schedule H.
1a Check the box(es) indicating under which section(s) you want your grant making procedures to be considered.
4945(g)(1) - Scholarship or fellowship grant to an individual for study at an educational institution
4945(g)(3) - Other grants, including loans, to an individual for travel, study, or other similar purposes, to enhance a particular skill of the
grantee or to produce a specific product
2

Do you represent that you will (1) arrange to receive and review grantee reports annually and upon completion of the
purpose for which the grant was awarded, (2) investigate diversions of funds from their intended purposes, and (3) take all
reasonable and appropriate steps to recover diverted funds, ensure other grant funds held by a grantee are used for their
intended purposes, and withhold further payments to grantees until you obtain grantees' assurances that future diversions
will not occur and that grantees will take extraordinary precautions to prevent future diversions from occurring?

Yes

Do you represent that you will maintain all records relating to individual grants, including information obtained to evaluate
grantees, identify whether a grantee is a disqualified person, establish the amount and purpose of each grant, and establish
that you undertook the supervision and investigation of grants described in Line 2?

Yes

Do you or will you award scholarships, fellowships, and educational loans to attend an educational institution based on the
status of an individual being an employee of a particular employer?

Yes

If "No," do not complete the rest of Schedule H.
5

Will you comply with the seven conditions and either the percentage tests or facts and circumstances test for scholarships,
fellowships, and educational loans to attend an educational institution as set forth in Revenue Procedures 76-47, 1976-2 C.B.
670, and 80-39, 1980-2 C.B. 772, which apply to inducement, selection committee, eligibility requirements, objective basis of
selection, employment, course of study, and other objectives?

Yes

Do you or will you provide scholarships, fellowships, or educational loans to attend an educational institution to employees
of a particular employer? If "No," continue to Line 7.

Yes

6a Will you award grants to 10% or fewer of the eligible applicants who were actually considered by the selection committee in
selecting recipients of grants in that year as provided by Revenue Procedures 76-47 and 80-39?

Yes

Do you provide scholarships, fellowships, or educational loans to attend an educational institution to children of employees
of a particular employer?
If "No," do not complete the rest of Schedule H.

7a Will you award grants to 25% or fewer of the eligible applicants who were actually considered by the selection committee in
selecting recipients of grants in that year as provided by Revenue Procedures 76-47 and 80-39?
If "Yes," do not complete the rest of Schedule H.

Form 1023 (Rev. 01-2020)

Name:

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EIN:

Schedule H. Organizations Providing Scholarships, Fellowships, Educational Loans, or Other Educational Grants to Individuals and Private
Foundations Requesting Advance Approval of Individual Grant Procedures (continued)
7b Will you award grants to 10% or fewer of the number of employees' children who can be shown to be eligible for grants
(whether or not they submitted an application) in that year, as provided by Revenue Procedures 76-47 and 80-39? If "Yes,"
describe how you will determine who can be shown to be eligible for grants without submitting an application, such as by
obtaining written statements or other information about the expectations of employees' children to attend an educational
institution; do not complete the rest of Schedule H.

7c Will you award grants based on facts and circumstances that demonstrate that the grants will not be considered
compensation for past, present, or future services or otherwise provide a significant benefit to the particular employer? If
"Yes," describe the facts and circumstances you believe will demonstrate that the grants are neither compensatory nor a
significant benefit to the particular employer. In your explanation, describe why you cannot satisfy either the 25% test or the
10% test in questions 7a and 7b.

Yes

Form 1023 (Rev. 01-2020)

File Type	application/pdf
File Modified	2021-11-03
File Created	2021-11-03