Form 1024 - Application For Recognition Of Exemption Under Section 501(A) Page 15
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2015
Form 1024 (Rev. 1-2018)
Page
Schedule G
Organizations described in section 501(c)(12) (Benevolent life insurance associations, mutual
ditch or irrigation companies, mutual or cooperative telephone companies, or like organizations)
1
Attach a schedule in columnar form for each tax year for which the organization is claiming exempt status. On each schedule:
a
Show the total gross income received from members or shareholders.
b
List, by source, the total amounts of gross income received from other sources.
2
If the organization is claiming exemption as a local benevolent insurance association, state:
a
The counties from which members are accepted or will be accepted.
b
Whether stipulated premiums are or will be charged in advance, or whether losses are or will be paid solely through assessments.
3
If the organization is claiming exemption as a “like organization,” explain how it is similar to a mutual ditch or irrigation company, or a mutual or
cooperative telephone company.
4
Are the rights and interests of members in the organization’s annual savings determined in proportion to their business
with it? .
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Yes
No
If “Yes,” does the organization keep the records necessary to determine at any time each member’s rights and interests
in such savings, including assets acquired with the savings? .
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Yes
No
5
If the organization is a mutual or cooperative telephone company and has contracts with other systems for long-distance telephone services,
attach copies of the contracts.
Instructions
Mutual or cooperative electric or telephone companies
performing services that involve their members and the
should show income received from qualified pole rentals
gross amount of income received from the sale of display
separately. Mutual or cooperative telephone companies
advertising in a directory furnished to their members.
should also show separately the gross amount of income
Do not net amounts due or paid to other sources
received from nonmember telephone companies for
against amounts due or received from those sources.
1024
Form
(Rev. 1-2018)
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