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

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.

Go to

for additional filing information.

Page

Form 1023-EZ (6-2014)

Part V

Reinstatement After Automatic Revocation

Complete this section only if you are applying for reinstatement of exemption after being automatically revoked for failure to

file required annual returns or notices for three consecutive years, and you are applying for reinstatement under section 4 or 7

of Revenue Procedure 2014-11. (Check only one box.)

Check this box if you are seeking retroactive reinstatement under section 4 of Revenue Procedure 2014-11. By checking this box, you attest

that you meet the specified requirements of section 4, that your failure to file was not intentional, and that you have put in place procedures

to file required returns or notices in the future. (See the instructions for requirements.)

Check this box if you are seeking reinstatement under section 7 of Revenue Procedure 2014-11, effective the date you are filling this

application.

Part VI

Signature

I declare under the penalties of perjury that I am authorized to sign this application on behalf of the above organization

and that I have examined this application, and to the best of my knowledge it is true, correct, and complete.

(Type name of signer)

(Type title or authority of signer)

PLEASE

SIGN

HERE

(Signature of Officer, Director, Trustee, or other authorized official)

(Date)

1023-EZ

Form

(6-2014)

Printed on recycled paper

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