Addition To Exemption Application Hospitals
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2Addition to Exemption
K.S.A. 79-201b First
Page 1 of 2
Applicant Name: ________________________
Docket No.:_____________________________
Addition to Exemption Application
K.S.A. 79-201b First (Hospitals)
1.
Name of organization.
_______________________________________________________________________________
2.
Name and address of related organization(s).
_______________________________________________________________________________
3.
Is the organization currently licensed to operate a hospital or psychiatric hospital?
_____No
_____Yes (If “Yes”, enclose a copy of the applicable license.)
4.
If the subject property is used for hospital purposes by a hospital, psychiatric hospital, or public hospital
authority, what types of services are provided and what hours are the services offered?
_______________________________________________________________________________
_______________________________________________________________________________
5.
If the subject property is used by more than one organization, provide the names of the other organizations
that use the property and explain in detail the uses of the property by the other organizations.
_______________________________________________________________________________
_______________________________________________________________________________
6.
Enclose the following documentation:
A copy of the Articles of Incorporation and Bylaws of the organization.
A copy of the Certificate of Good Standing issued by the Kansas Secretary of State
demonstrating that the organization is currently active and in good standing.
A copy of the IRS designation letter showing exemption pursuant to I.R.C. §501(c)(3).
A copy of the license issued by the proper licensing authority, if applicable.
Revised 07/14
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