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You must complete the Form 1023-EZ Eligibility Worksheet in the Instructions for Form 1023-EZ to

determine if you are eligible to file this form. Form 1023-EZ is filed electronically only on Pay.gov.

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for additional filing information.

1023-EZ

Streamlined Application for Recognition of Exemption

OMB No. 1545-0056

Form

Under Section 501(c)(3) of the Internal Revenue Code

(June 2014)

Note: If exempt status is

Do not enter social security numbers on this form as it may be made public.

approved, this application will

Department of the Treasury

be open for public inspection.

Information about Form 1023-EZ and its separate instructions is at

Internal Revenue Service

Check this box to attest that you have completed the Form 1023-EZ Eligibility Worksheet in the current instructions, are eligible to apply

for exemption using Form 1023-EZ, and have read and understand the requirements to be exempt under section 501(c)(3).

Part I

Identification of Applicant

1a Full Name of Organization

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

c City

d State e Zip Code + 4

Employer Identification Number

3 Month Tax Year Ends (MM)

4 Person to Contact if More Information is Needed

Contact Telephone Number

6 Fax Number (optional)

7 User Fee Submitted

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

First Name:

Last Name:

Title:

Street Address:

City:

State:

Zip Code + 4:

First Name:

Last Name:

Title:

Street Address:

City:

State:

Zip Code + 4:

First Name:

Last Name:

Title:

Street Address:

City:

State:

Zip Code + 4:

First Name:

Last Name:

Title:

Street Address:

City:

State:

Zip Code + 4:

First Name:

Last Name:

Title:

Street Address:

City:

State:

Zip Code + 4:

9 a Organization's Website (if available):

b Organization's Email (optional):

Part II

Organizational Structure

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

Corporation

Unincorporated association

Trust

Check this box to attest that you have the organizing document necessary for the organizational structure indicated above.

(See the instructions for an explanation of necessary organizing documents.)

3 Date incorporated if a corporation, or formed if other than a corporation (MMDDYYYY):

4 State of incorporation or other formation:

5 Section 501(c)(3) requires that your organizing document must limit your purposes to one or more exempt purposes within section 501(c)(3).

Check this box to attest that your organizing document contains this limitation.

6 Section 501(c)(3) requires that your organizing document must not expressly empower you to engage, otherwise than as an insubstantial part of

your activities, in activities that in themselves are not in furtherance of one or more exempt purposes.

Check this box to attest that your organizing document does not expressly empower you to engage, otherwise than as an insubstantial

part of your activities, in activities that in themselves are not in furtherance of one or more exempt purposes.

7 Section 501(c)(3) requires that your organizing document must provide that upon dissolution, your remaining assets be used exclusively for

section 501(c)(3) exempt purposes. Depending on your entity type and the state in which you are formed, this requirement may be satisfied by

operation of state law.

Check this box to attest that your organizing document contains the dissolution provision required under section 501(c)(3) or that you do

not need an express dissolution provision in your organizing document because you rely on the operation of state law in the state in which

you are formed for your dissolution provision.

1023-EZ

)

For Paperwork Reduction Act Notice, see the instructions.

Form

(6-2014

Catalog No. 66267N

Form 1023-Ez - Streamlined Application For Recognition Of Exemption Under Section 501(C)(3) Of The Internal Revenue Code - 2014

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