1024 Application for Recognition of Exemption Under Section 5

U.S. Tax-Exempt Income Tax Return

f1024--2022-01-00

Forms, Schedules, and Instructions for Return of Exempt Organizations From Income Tax Under Section 501(c), 527, or 4947(a)(1)

OMB: 1545-0047

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Form

1024

Application for Recognition of Exemption
Under Section 501(a) or Section 521
of the Internal Revenue Code

(Rev. January 2022)
Department of the Treasury
Internal Revenue Service

OMB No. 1545-0047

Do not enter social security numbers on this form as it may be made public.
Go to www.irs.gov/Form1024 for instructions and the latest information.

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

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 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

Full Name of Organization (exactly as it appears in your organizing document)

Care of Name (if applicable)

Mailing Address (number, street and room/suite)

4 City

5 Country
United States

7 Zip Code + 4

State

10 Employer Identification Number

8 Foreign Province (or State)

11 Month Tax Year Ends

13 Contact Telephone Number

9 Foreign Postal Code

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

14 Fax Number (optional)

15 User Fee Submitted

16 Organization's Website (if available):
17 List the names, titles, and mailing addresses of your officers, directors, and/or trustees.
First Name:

Last Name:

Mailing Address:
State (or Province):
First Name:

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

Mailing Address:

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

Mailing Address:

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

Mailing Address:

Title:
City:

State (or Province):
First Name:

Title:
City:

State (or Province):
First Name:

Title:
City:

State (or Province):
First Name:

Title:
City:

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.

Catalog No. 12343K

Form 1024 (Rev. 01-2022)

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.

Yes

Form 1024 (Rev. 01-2022)

Part II
5

Name:

Page 3

EIN:

Organizational Structure (continued)

Check the appropriate box below to indicate the section under which you are applying:
Section 501(c)(2)—Title holding corporations (Schedule A)
Section 501(c)(5)—Labor, agricultural, or horticultural organizations (Schedule B)
Section 501(c)(6)—Business leagues, chambers of commerce, etc. (Schedule C)
Section 501(c)(7)—Social clubs (Schedule D)
Section 501(c)(8)—Fraternal beneficiary societies, etc., providing life, sick, accident, or other benefits to members (Schedule E)
Section 501(c)(9)—Voluntary employees' beneficiary associations (Schedule F)
Section 501(c)(10)—Domestic fraternal societies, orders, etc., not providing life, sick, accident, or other benefits (Schedule E)
Section 501(c)(11)—Teachers' Retirement Fund Associations
Section 501(c)(12)—Benevolent life insurance associations, mutual ditch or irrigation companies, mutual or cooperative telephone
companies, or like organizations (Schedule G)
Section 501(c)(13)—Cemeteries, crematoria, and like corporations (Schedule H)
Section 501(c)(14)—Credit Unions (Schedule I)
Section 501(c)(15)—Mutual insurance companies or associations, other than life or marine (See Instructions for Part III)
Section 501(c)(16)—Corporations organized to finance crop operations
Section 501(c)(17)—Trusts providing for the payment of supplemental unemployment compensation benefits (Schedule J)
Section 501(c)(18)—Employee funded pension trusts (created before June 25, 1959)
Section 501(c)(19)—A post, organization, auxiliary unit, etc., of past or present members of the Armed Forces of the United States
(Schedule K)
Section 501(c)(21)— Black Lung Benefit Trusts
Section 501(c)(22)—Withdrawal Liability Payment Funds
Section 501(c)(23)—Veterans' organizations (created before 1880)
Section 501(c)(25)—Title holding corporations or trusts with multiple parents (Schedule A)
Section 501(c)(26)—State-Sponsored High-Risk Health Coverage Organizations
Section 501(c)(27)—State-Sponsored Worker's Compensation Reinsurance Organizations
Section 501(c)(28)—National Railroad Retirement Investment Trust
Section 501(c)(29)—Qualified Nonprofit Health Insurance Issuers (See Instructions for Part III)
Section 501(d)—Religious and apostolic organizations (Schedule L)
Section 521—Farmers' Cooperative Associations (Schedule M)

Form 1024 (Rev. 01-2022)

Part III
1

Name:

EIN:

Page 4

Your Activities

Describe completely and in detail your past, present, and planned activities. Do not refer to or repeat the purposes in your organizing
document or speculate about potential future programs. Your narrative description of activities should be thorough and accurate because
we determine whether you qualify for exempt status based on the information in your application.
For each past, present, or planned activity, include information that answers the following questions:
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 1024 (Rev. 01-2022)

Part III
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 you or will you spend any money or time attempting to influence the selection, nomination, election, or
appointment of any person to any federal, state, or local public office or to an office in a political organization? If
"Yes," explain in detail and list the amounts of money and time you spent or plan to spend in each case.

Yes

Are you a successor to another organization? Answer "Yes" if you have taken or will take over the activities of
another organization, you took over 25% or more of the fair market value of the net assets of another organization,
or you were established upon the conversion of an organization from for-profit to nonprofit status. If "Yes," explain. If
"No," continue to Line 5.

Yes

Are you a successor to a for-profit organization?

Yes

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).

Form 1024 (Rev. 01-2022)

Part III

Name:

Page 6

EIN:

Your Activities (continued)

Explain your relationship with your predecessor organization and why you took over its activities or assets or converted from for-profit to
nonprofit status.

Do you or will you maintain a working relationship with any of the persons listed in Line 4c 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 if an appraisal was
obtained, at the end of this form upload a copy. 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 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

Form 1024 (Rev. 01-2022)

Part III

Name:

Page 7

EIN:

Your Activities (continued)

Will you lease or rent any property or equipment to or from the predecessor organization or any persons listed in
Line 4c 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

Do you have members? If "Yes," state your membership requirements, your classes of membership, the number of
members in each class, and the voting rights or privileges associated with each class. If any group or class of
persons is required to join, describe the requirement and explain the relationship between those members and
members who join voluntarily.

Yes

Do you or will you make any distributions of property or surplus funds to shareholders or members? If "Yes," explain.

Yes

Have you or will you issue capital stock? If "Yes," state the class or classes of stock, number and par value of the
shares, consideration for which stock was issued, and if any dividends have been or will be paid.

Yes

Form 1024 (Rev. 01-2022)

Part III

Name:

Page 8

EIN:

Your Activities (continued)

Explain how your assets will be distributed upon dissolution.

Do you or will you have any arrangement to provide insurance for members, their dependents, or others (including
provisions for the payment of sick or death benefits, pensions, or annuities)? If "Yes," describe the arrangement,
including the terms and conditions of eligibility for membership and benefits.

Yes

Do you or will you make grants, loans, or other distributions to foreign organizations? If "Yes," name each foreign
organization, 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 11.

Yes

10a 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

Form 1024 (Rev. 01-2022)

Part III

Name:

Page 9

EIN:

Your Activities (continued)

10b 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

10c Do you share board members or other key personnel with the recipient organizations? If "Yes," identify the
relationships.

Yes

10d When you make grants, loans, or other distributions to foreign organizations, will you check the Office of Foreign
Assets Control (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-exempt
activities.

Yes

10e 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

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

Yes

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 Part IV.

Form 1024 (Rev. 01-2022)

Part III

Name:

Page 10

EIN:

Your Activities (continued)

11a When you conduct activities in foreign countries, will you check the Office of Foreign Assets Control (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-exempt activities.

Yes

11b 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

11c Will you acquire from OFAC the appropriate license and registration where necessary?

Yes

Part IV

Compensation and Other Financial Arrangements

Do you or will you compensate your officers, directors, trustees, employees, members, or independent contractors?
If "No," continue to Line 2.

Yes

Do or will the individuals that approve compensation arrangements follow a conflict of interest policy? If "No,"
describe how you set compensation that is reasonable.

Yes

Do you or will you compensate any of your officers, directors, trustees, employees, members, or independent
contractors through nonfixed payments, such as discretionary bonuses or revenue-based payments? If "Yes,"
describe all nonfixed compensation agreements.

Yes

Form 1024 (Rev. 01-2022)

Part IV

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; (v) your highest compensated
independent contractors; or (vi) any member of your organization? 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; (v) your highest compensated
independent contractors; or (vi) any member of your organization? 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 be paid for services you perform? If "Yes," describe these services, the income and expenses
related to the services, and how they further your exempt purposes.

Yes

Do you or will 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," for each joint venture, state your
ownership percentage and your investment in each joint venture, describe the tax status of all other participants,
describe the activities of each and how you exercise control over those activities, and describe how each joint
venture furthers your exempt purposes.

Yes

Form 1024 (Rev. 01-2022)

Part V

Name:

Page 12

EIN:

Financial Data
A. Statement of Revenues and Expenses
Type of revenue

Current tax year

2 prior or succeeding tax years

From:

__/__/____

From:

__/__/____

From:

__/__/____

To:

__/__/____

To:

__/__/____

To:

__/__/____

1 Gifts, grants, and contributions received
2 Membership fees received
3 Gross investment income
4 Net unrelated business income
5 Taxes levied for your benefit
6 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)
7 Any revenue not otherwise classified (provide an
itemized list below)
8 Total of lines 1 through 7
9 Gross receipts from any activity that is related to your
exempt purpose (provide an itemized list below)

$0.

10 Total of lines 8 and 9
11 Net gain or loss on sale of capital assets (provide an
itemized list below)

$0.

12 Total Revenue

$0.

Type of expense

$0.

Current tax year

$0.

2 prior or succeeding tax years

13 Fundraising expenses
14 Contributions, gifts, grants, and similar amounts paid
out (provide an itemized list below)
15 Disbursements to or for the benefit of members
(provide an itemized list below)
16 Compensation of officers, directors, and trustees
17 Other salaries and wages
18 Interest expense
19 Occupancy (rent, utilities, etc.)
20 Depreciation and depletion
21 Professional fees
22 Any expense not otherwise classified, such as
program services (provide an itemized list below)
23 Total Expenses

$0.

24 Itemized financial data

Form 1024 (Rev. 01-2022)

Part V

Name:

Page 13

EIN:

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

Year End:

Assets
1 Cash
2 Accounts receivable, net
3 Inventories
4 Bonds and notes receivable (provide an itemized list below)
5 Corporate stocks (provide an itemized list below)
6 Loans receivable (provide an itemized list below)
7 Other investments (provide an itemized list below)
8 Depreciable assets (provide an itemized list below)
9 Land
10 Other assets (provide an itemized list below)
11 Total Assets

$0.

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

$0.

Fund Balances or Net Assets
17 Total fund balances or net assets
18 Total Liabilities and Fund Balances or Net Assets

$0.

19 Itemized financial data

Form 1024 (Rev. 01-2022)

Part VI

Name:

Page 14

EIN:

Reinstatement After Automatic Revocation

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 Part VII.

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.

Yes

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.
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.
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.
Section 7. You are seeking reinstatement under section 7 of Revenue Procedure 2014-11, effective the date you are filing this
application.

Form 1024 (Rev. 01-2022)

Part VII

Name:

Page 15

EIN:

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

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?

Yes

If "Yes," are you claiming you are excepted from filing because you are:
An affiliate of a governmental unit that meets the requirements of Revenue Procedure 95-48, 1995-2 C.B. 418
Other (describe)

Part VIII

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)
12/08/2023

(Date)

Form 1024 (Rev. 01-2022)

Name:

EIN:

Page 16

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 1024 (Rev. 01-2022)

Schedule A

Name:

Page 17

EIN:

Organizations described in section 501(c)(2) or 501(c)(25)—Title holding corporations or trusts

List the name, address, and EIN of the organization(s) for which title to property is held.

Describe the property to which you hold or will hold title.

Do you or will you turn over the entire amount of your income, less expenses, to the organization(s) for which title to
property is held? If "No," state the purpose for which the excess is or will be retained.

Yes

Do you or will you engage in any activities other than holding title to property and collecting income therefrom? If
"Yes," describe those activities in detail.

Yes

Check the appropriate box below to indicate the section under which you are applying:
Section 501(c)(2)—Title holding corporations (continue to Line 6)
Section 501(c)(25)—Title holding corporations or trusts with multiple parents

Are your shareholders or beneficiaries permitted to dismiss your investment adviser upon a majority vote?

Yes

Are your shareholders or beneficiaries permitted to terminate their interest in you by selling or exchanging their stock
or interest to any organization described in section 501(c)(25)(C) so long as the sale or exchange does not increase
the number of your shareholders or beneficiaries above 35, or by having their stock or interest redeemed by you
after they provide you 90 days' notice?

Yes

Form 1024 (Rev. 01-2022)

Schedule A

Name:

Page 18

EIN:

Organizations described in section 501(c)(2) or 501(c)(25)—Title holding corporations or trusts (continued)

Do you or will you hold interests in partnerships or real estate trusts? If "Yes," explain.

Yes

Do you or will you make mortgage loans? If "Yes," explain.

Yes

Do you or will you hold property through a corporation, partnership, or trust? If "Yes," explain.

Yes

Do you or will you receive rent attributable to personal property leased with real property? If "Yes," what percentage
of the total rent is attributable to personal property?

Yes

Form 1024 (Rev. 01-2022)

Schedule A

Name:

Page 19

EIN:

Organizations described in section 501(c)(2) or 501(c)(25)—Title holding corporations or trusts (continued)

Do you or will you receive income which is incidentally derived from the holding of real property, such as income
from operation of a parking lot or from vending machines? If "Yes," what percentage of your gross income is
incidentally derived from the holding of real property?

Yes

Will you receive income other than rent from real property or personal property leased with real property or income
which is incidentally derived from the holding of real property? If "Yes," describe the source of the income.

Yes

Form 1024 (Rev. 01-2022)

Schedule B
1

Name:

Page 20

EIN:

Organizations described in section 501(c)(5)—Labor, agricultural, or horticultural organizations

Select your type of organization from the list below.
Labor organization
Agricultural organization (continue to Line 3)
Horticultural organization (continue to Line 3)

Are you organized under the terms of a collective bargaining agreement? If "Yes," at the end of this form, upload a
current copy. Continue to Line 4.

Describe the products your members produce or will produce, if applicable. If you are a fishermen's organization, describe the kinds of
aquatic resources that are cultivated or harvested by your members.

Describe any services you perform or will perform for members or others.

Yes

Form 1024 (Rev. 01-2022)

Schedule C
1

Name:

Page 21

EIN:

Organizations described in section 501(c)(6)—Business leagues, chambers of commerce, etc.

Select your type of organization from the list below.
Business league
Chamber of commerce
Real estate board
Board of trade
Professional football league

Describe your members' common business interests.

Describe any services you perform or will perform for members or others.

Do you or will you restrict your membership to individuals, firms, associations, and/or corporations, each
representing a different trade, business, occupation, or profession, and organized for the purpose of exchanging
information on business prospects? If "Yes," explain.

Yes

Do you or will you market a specific product(s) and/or brand(s) within an industry? If "Yes," explain.

Yes

Form 1024 (Rev. 01-2022)

Schedule C

Name:

Page 22

EIN:

Organizations described in section 501(c)(6)—Business leagues, chambers of commerce, etc. (continued)

Do you or will you limit your activities to users of a specific product within an industry? If "Yes," explain.

Yes

Do you or will you operate a listing or referral system? If "Yes," explain.

Yes

Form 1024 (Rev. 01-2022)

Schedule D

Name:

Page 23

EIN:

Organizations described in section 501(c)(7)—Social clubs

Do you have regular meetings, gatherings, or facilities where commingling of your members takes place? If "No,"
explain.

Yes

Do you or will you conduct activities such as take-out food sales, liquor sales, operation of a gas station, parking
garage, barber shop, etc.? If "Yes," describe these activities and indicate the percentage of your time and resources
devoted to them.

Yes

Do you or will you enter into any contracts or agreements for the management or operation of your property and/or
activities, such as restaurants, pro shops, lodges? 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 receive income from non-members? If "Yes," explain.

Yes

Form 1024 (Rev. 01-2022)

Schedule D

Name:

Page 24

EIN:

Organizations described in section 501(c)(7)—Social clubs (continued)

Are non-members, other than guests of members, permitted or will they be permitted to use the club facilities or
participate in or attend any functions or activities you conduct? If "Yes," describe the functions or activities in which
there has been or will be non-member participation or admittance.

What percent of gross receipts do you or will you receive from non-members for the use of club facilities and/or
attendance at club events?

What percent of gross receipts do you or will you receive from investment income?

Yes

Does your charter, bylaws, other governing instrument, or any written policy statement contain any provision that
provides for discrimination against any person on the basis of race, color, or religion?

Yes

Do you restrict your membership to members of a particular religion? If "Yes," explain.

Yes

Are you an auxiliary of a section 501(c)(8) fraternal beneficiary society? If "Yes," list their name, address, and EIN.

Yes

Do you, in good faith, limit membership to the members of a particular religion in order to further the teachings or
principles of that religion and not to exclude individuals of a particular race or color?

Yes

Form 1024 (Rev. 01-2022)

Schedule E

Name:

Page 25

EIN:

Organizations described in section 501(c)(8) or 501(c)(10)—Fraternal beneficiary societies, orders, or associations

Do you or will you operate under the lodge system?

Yes

Do you or will you operate for the exclusive benefit of the members of an organization operating under the lodge
system? If "Yes," explain.

Yes

Are you a subordinate or local lodge, etc.? If "Yes," list the the name, address, and EIN of your parent organization.

Yes

Are you a parent or grand lodge? If "Yes," list the name, address, and EIN of each subordinate lodge in active
operation.

Yes

Form 1024 (Rev. 01-2022)

Schedule F
1

Name:

Page 26

EIN:

Organizations described in section 501(c)(9)—Voluntary employees' beneficiary associations

Describe the benefits you provide or will provide. For each benefit include the account, duration, eligibility requirements, and the
circumstances that will entitle a recipient to payment of the benefit.
At the end of this form, upload copies of any plan documents and insurance policies that describe such benefits and the terms and
conditions of eligibility for each benefit.

Do you or will you provide deferred compensation benefits, property or malpractice insurance, loans (other than
loans at times of disaster or whole life insurance policy loans), savings plans, reimbursement of commuting
expenses, or benefits similar to those provided by a pension, stock bonus or profit sharing plan? If "Yes," explain.

Give the following information for each plan as of the last day of the most recent plan year and enter that date here. If there is more than
one plan, at the end of this form, upload a separate schedule.

Yes

Year End:
Total number of persons covered by the plan who are highly compensated individuals
Number of other employees covered by the plan
Number of employees not covered by the plan
Total number employed
4

State the number of persons, if any, other than employees and their dependents (for example, the proprietor of a
business whose employees are members of the association) who are entitled to receive benefits.

Are any employees or classes of employees entitled to benefits to which other employees or classes of employees
are not entitled? If "Yes," explain.

Yes

Form 1024 (Rev. 01-2022)

Schedule F

Name:

Page 27

EIN:

Organizations described in section 501(c)(9)—Voluntary employees' beneficiary associations (continued)

Are you organized under the terms of a collective bargaining agreement? If "Yes," at the end of this form, upload a
current copy.

Yes

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

Yes

Generally, if you did not file Form 1024 within 27 months of formation, the effective date of your exempt status will be the date you filed
Form 1024 (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.
Check this box if you are requesting an earlier effective date than the submission date.

Explain why you did not file Form 1024 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 1024 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 1024 (Rev. 01-2022)

Schedule G
1

Name:

Page 28

EIN:

Organizations described in section 501(c)(12)—Benevolent life insurance associations, mutual ditch or irrigation
companies, mutual or cooperative telephone companies, or like organizations

Select your type of organization from the list below.
Benevolent life insurance association or like organization
Mutual ditch or irrigation company or like organization (continue to Line 4)
Mutual or cooperative telephone company or like organization (continue to Line 4)
Mutual or cooperative electric company or like organization (continue to Line 4)

Will your business activities be confined to a particular community, place, or district? If "No", explain.

List the counties or geographical region from which members are accepted or will be accepted. Continue to Line 8.

Yes

Do members have democratic control? If "No," explain.

Yes

Are the rights and interests of members in your annual savings determined in proportion to their business with you?

Yes

Do you keep the records necessary to determine at any time each member's rights and interests in such savings,
including assets acquired with the savings?

Yes

Form 1024 (Rev. 01-2022)

Schedule G

Name:

Page 29

EIN:

Organizations described in section 501(c)(12)—Benevolent life insurance associations, mutual ditch or irrigation
companies, mutual or cooperative telephone companies, or like organizations (continued)

Are the rights and interests of members forfeited upon termination of membership? If "Yes," explain.

Yes

Do you or will you receive at least 85% of your gross income annually from amounts collected from members for the
sole purposes of meeting losses and expenses. If "No," explain.

Yes

Form 1024 (Rev. 01-2022)

Schedule H

Name:

Page 30

EIN:

Organizations described in section 501(c)(13)—Cemeteries, crematoria, and like corporations

Are you claiming exemption as a perpetual care fund for an organization described in section 501(c)(13)?

Yes

Has the cemetery organization, for which funds are held, established exemption under section 501(c)(13)? If "No,"
explain.

Yes

Are your funds devoted exclusively to the perpetual care and maintenance of the non-profit cemetery as a whole? If
"No," explain.

Yes

Do you or will you operate a mortuary?

Yes

Do you or will you engage in land sale agreements, percentage-of-sales agreements, or other similar financial
arrangements? If "Yes," describe any written or oral arrangements that you have 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 own, operate, or maintain a cemetery for pets?

Yes

Form 1024 (Rev. 01-2022)

Schedule I

Name:

Page 31

EIN:

Organizations described in section 501(c)(14)—Credit Unions

Are you formed under a state credit union law? If "No," continue to Line 7.

Select the state credit union law under which you are organized and operated.

Yes

Are you being operated under uniform bylaws adopted by the state you selected in Line 2? If "No," explain.

Yes

In making loans, do you or will you comply with the state credit union law requirements, including their purposes,
security, and rate of interest charged thereon? If "No," explain.

Yes

Do you or will you limit your investments to securities which are legal investments for credit unions under the state
credit union law? If "No," explain.

Yes

Do you or will you distribute dividends on shares, if any, as prescribed by the state credit union law? If "No," explain.

Yes

Are you operated for the mutual benefit of your members?

Yes

Form 1024 (Rev. 01-2022)

Schedule I

Name:

Page 32

EIN:

Organizations described in section 501(c)(14)—Credit Unions (continued)

Is there a common bond among your members (e.g., association, occupation, or residence)? If "Yes," explain.

Describe how your governing board and officers are selected.

Yes

Do you or will you issue certificates of stock to shareholders? If "Yes," explain.

Yes

Do you or will you allow non-members to be shareholders? If "Yes," explain.

Yes

Do you or will you ensure that loans to members benefit the borrower and meet their needs? If "No," explain.

Yes

Form 1024 (Rev. 01-2022)

Schedule I

Name:

Page 33

EIN:

Organizations described in section 501(c)(14)—Credit Unions (continued)

Do you or will you make loans to non-members? If "Yes," explain.

Yes

Do you or will you advertise to non-members? If "Yes," explain.

Yes

Are you a mutual reserve fund organized before September 1, 1957?

Yes

15a Do you provide reserve funds for-- and insurance of shares or deposits in-- a domestic building and loan association,
cooperative bank without capital stock organized and operated for mutual purposes and without profit, mutual
savings bank not having capital stock represented by shares, or a mutual savings bank described in section 591(b)?
15b Select the type(s) of organization(s) you provide reserve funds for and insurance of shares or deposits in:
Domestic building and loan associations
Cooperative banks without capital stock organized and operated for mutual purposes and without profit
Mutual savings banks not having capital stock represented by shares
Mutual savings banks described in section 591(b)
15c Enter the name of the organization(s) you provide reserve funds for and insurance of shares or deposits in.

15d Is 85% or more of your income attributable to providing reserve funds and to investments? If "No," explain.

Form 1024 (Rev. 01-2022)

Schedule J
1

Name:

Page 34

EIN:

Organizations described in section 501(c)(17)—Trusts providing for the payment of supplemental unemployment
compensation benefits

Describe the benefits you provide or will provide. Include the amount, duration, eligibility requirements, and the circumstances that will
entitle a recipient to payment of the benefit.
At the end of this form, upload copies of any plan documents that describe such benefits and the terms and conditions of eligibility for
each benefit.

Do you or will you provide benefits for individual proprietors, partners, or self-employed persons under the plan? If
"Yes," explain.

Yes

Year End:
Total number of persons covered by the plan who are shareholders, officers, self-employed persons, or highly
compensated
Number of other employees covered by the plan
Number of employees not covered by the plan
Total number employed
4

Have or will the creator of the trust or a contributor to the trust; a brother or sister (whole or half-blood), a spouse, an
ancestor, or a lineal descendant of such a creator or contributor; or a corporation controlled directly or indirectly by
such a creator or contributor (i) borrow or receive any part of the trust's income or corpus, (ii) receive any
compensation for personal services, (iii) obtain any part of the trust’s services, or (iv) sell or purchase any securities
or other properties from or to the trust?

Yes

Form 1024 (Rev. 01-2022)

Schedule J

Name:

Page 35

EIN:

Organizations described in section 501(c)(17)—Trusts providing for the payment of supplemental unemployment
compensation benefits (continued)

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

Yes

Check this box if you accept the submission date as the effective date of your exempt status.
Check this box if you are requesting an earlier effective date than the submission date.
5b

Form 1024 (Rev. 01-2022)

Schedule K

Name:

Page 36

EIN:

Organizations described in section 501(c)(19)—A post, organization, auxiliary unit, etc., of past or present members of
the Armed Forces of the United States

Are you applying as a post or organization of past or present members of the Armed Forces of the United States?

How many total members do you have?

How many of your members are present or former members of the U.S. Armed Forces?

How many of your members are cadets (include students in college or university ROTC programs or at armed
services academies only), or spouses, widows, or widowers of cadets or past or present members of the U.S. Armed
Forces?

Yes

Do you have a membership category other than the ones set out above? If "Yes," describe other membership
categories and state the number of members in each category.

Yes

Do you wish to apply for a determination that contributions to your organization are deductible by donors?

Yes

How many of your members from Line 1b are war veterans? (A war veteran is a person who served in the Armed
Forces of the United States during the following periods of war: April 21, 1898, through July 4, 1902; April 6, 1917,
through November 11, 1918; December 7, 1941, through December 31, 1946; June 27, 1950, through January 31,
1955; August 5, 1964, through May 7, 1975; and August 2, 1990, through a future date to be set by law or
Presidential Proclamation.)

Are you an auxiliary unit or society of a post or organization of past or present members of the Armed Forces of the
United States? If "Yes," list the name, address, and EIN of the post or organization.

Yes

Are you affiliated with and organized according to the bylaws and regulations formulated by such an exempt post or
organization? If "Yes," submit a copy of such bylaws or regulations at the end of this form.

Yes

How many total members do you have?

How many of your members are themselves past or present members of the Armed Forces of the United States, or
are their spouses, or persons related to them within two degrees of blood relationship? (Grandparents, brothers,
sisters, and grandchildren are the most distant relationships allowable.)

Are all of your members themselves members of a post or organization, past or present members of the Armed
Forces of the United States, spouses of members of such a post or organization, or related to members of such a
post or organization within two degrees of blood relationship?

Yes

Form 1024 (Rev. 01-2022)

Schedule K

Name:

Page 37

EIN:

Organizations described in section 501(c)(19)—A post, organization, auxiliary unit, etc., of past or present members of
the Armed Forces of the United States (continued)

Are you a trust or foundation organized for the benefit of an exempt post or organization of past or present members
of the Armed Forces of the United States?

Yes

Will your corpus or income be used solely for the funding of such an exempt organization (including necessary
related expenses)? If "No," explain.

Yes

If you are formed for charitable purposes, does your organizational document contain a proper dissolution provision
as described in section 1.501(c)(3)-1(b)(4) of the Income Tax Regulations?

Yes

Do you or will you (i) rent your facilities to the general public; (ii) make your facilities, such as bar and dining facilities,
open to the general public; (iii) sell liquor and/or food to members and/or the general public for consumption off
premises; or (iv) conduct gaming activities with the general public? If "Yes," explain.

Yes

Form 1024 (Rev. 01-2022)

Schedule L

Name:

Page 38

EIN:

Organizations described in section 501(d)—Religious and apostolic organizations

Are you organized for the purpose of operating a communal religious community where members live a communal
life following your tenets and teachings?

Yes

Do you maintain a common or community treasury?

Yes

Do all of your members live in a communal manner?

Yes

Are members permitted to own, in their own names, any real or personal property?

Yes

Are members required to furnish their own support (food, clothing, and shelter)?

Yes

State your membership requirements, the method of member admission, members' right to property owned at the time they're admitted and
terminating members' rights to share in the organization's property, or to a return of any property contributed.

Form 1024 (Rev. 01-2022)

Schedule M
1

Name:

Page 39

EIN:

Organizations described in section 521—Farmers' Cooperative Associations

Complete the table below to show the number of shares of each class of capital stock currently outstanding, the value of the consideration
for which it was issued, and the rate of dividend paid.
Class of stock
Shares
Amount
Rate of dividend
Preferred stock (voting)
Preferred stock (non-voting)
Common stock (voting)
Common stock (non-voting)

Complete the table below to show the number of shares of capital stock (other than non-voting preferred) owned by current and active
producers, inactive producers, and non-producers.
Owner

Current and active producers
Inactive producers
Non-producers
Total number of shares
Percentage owned by current and active producers
3

Do you or will you issue non-voting preferred stock? If "Yes," explain whether the owners, upon dissolution or
liquidation, may share in the profits of the association beyond fixed dividends.

Yes

Do you or will you make any provisions for retiring the voting stock held by a non-producer? If "Yes," explain.

Yes

Enter the legal rate of interest in the state where you are located.

Does state law require you to accumulate and maintain reserves? If "Yes," state the names and purposes of the
reserves and specify the amounts.

Yes

Form 1024 (Rev. 01-2022)

Schedule M

Name:

Page 40

EIN:

Organizations described in section 521—Farmers' Cooperative Associations (continued)

Do you or will you maintain any reserves other than those required by state law? If "Yes," state the names and
purposes of the reserves and specify the amounts.

Describe who is accorded voting rights in the cooperative and how many votes one person may have.

Yes

Are you a federated cooperative? If "No," continue to Line 12.

Yes

Are all your member cooperatives exempt under section 521? If "Yes," continue to Line 12.

Yes

Do the nonexempt member cooperatives have the same annual accounting period as you? If "No," describe the
method that you do or will use to provide a common or comparable unit of time for analyzing and evaluating your
operations and those of your members.

Yes

Do you or will you do business with both members and non-members? If "Yes," explain.

Yes

Form 1024 (Rev. 01-2022)

Schedule M

Name:

Page 41

EIN:

Organizations described in section 521—Farmers' Cooperative Associations (continued)

Do you or will you pay patronage dividends? If "Yes," explain whether they will be paid to members and nonmembers on the same basis. If "No," continue to Line 15.

Yes

Do you or will you allocate patronage dividends based on an obligation in existence before you received the
amounts allocated? If "Yes," explain the obligation in detail.

Yes

Explain how distribution is or will be made of the proceeds of products marketed for members and non-members. Also, if you operate on a
basis of allocated units (i.e., functional, departmental, etc.), explain how losses are or will be treated.

Explain how you charge for supplies and equipment purchased for members and non-members.

Form 1024 (Rev. 01-2022)

Schedule M

Name:

Current tax year

Page 42

EIN:

Organizations described in section 521—Farmers' Cooperative Associations (continued)
2 prior tax years

From:

__/__/____

From:

__/__/____

From:

__/__/____

To:

__/__/____

To:

__/__/____

To:

__/__/____

Value of agricultural products marketed or handled for:
a Members 1. Actually produced by members
2. Not actually produced by members but marketed by
them through you
b Non-members 1. Actually produced by non-members
2. Not actually produced by non-members but marketed
by them through you
c Nonproducers (purchased from nonproducers for
marketing by you)

Value of supplies and equipment purchased for or sold to:
a Members who were producers
b Non-members who were producers
c Members and non-members who were not producers

Amount of business done with the United States
Government or any of its agencies

Were all the net earnings (after payment of dividends, if any, on capital stock) for the years shown on Lines 17-19
distributed as patronage dividends?

Yes

If "No," were undistributed net earnings apportioned on the records to all patrons on a patronage basis?

Yes

Form 1024 (Rev. 01-2022)

File Type	application/pdf
File Modified	2023-12-08
File Created	2023-12-08