Form 1023-Ez Draft - Streamlined Application For Recognition Of Exemption Under Section 501(C)(3) Of The Internal Revenue Code
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1
2Version A, Cycle 4
1023-EZ
Streamlined Application for Recognition of Exemption
OMB No. 1545-0056
Form
Under Section 501(c)(3) of the Internal Revenue Code
Note: If exempt status is
(Rev. June 2014)
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 dated [INSERT DATE] and are eligible to apply for an
exemption using Form 1023-EZ.
Part I
Identification of Applicant
1 Full name of organization (exactly as it appears in your organizing document)
2 c/o Name (if applicable)
3 Mailing address (number and street) (see instructions)
Room/Suite
4 Employer identification number (EIN)
City, town or post office, state, and ZIP + 4
5 Month the annual accounting period ends (01 - 12)
6 List the names, titles, and mailing addresses of all your officers, directors, and trustees. (Attach a statement if additional space is needed.)
INTERNAL USE ONLY
DRAFT AS OF
7 Primary contact (officer, director, trustee, or authorized representative)
a Name:
b Phone:
February 19, 2014
c Fax (optional):
8 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
2
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 (mm/dd/yyyy)
4
State of incorporation or other formation:
5
Section 501(c)(3) requires that your organizing document must limit the purposes of your organization 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 your organization to engage, other 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 your organization to engage, other 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 of your organization, your remaining assets must
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
(Rev. 6-2014
Catalog No. 66267N
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