Form 1023-Ez Draft - Streamlined Application For Recognition Of Exemption Under Section 501(C)(3) Of The Internal Revenue Code Page 2

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Version A, Cycle 4

Page

Form 1023-EZ (Rev. 6-2014)

Part III

Your Specific Activities

1 Enter the appropriate 3-digit NTEE Code that best describes your activities (See the instructions):

2 To qualify for exemption as a section 501(c)(3) organization, you must be organized and operated exclusively to further one or more of the

following purposes. By checking the box or boxes below, you attest that you are organized and operated exclusively to further the purposes

indicated. Check all that apply.

Charitable

Religious

Educational

Scientific

Literary

Testing for public safety

To foster national or international amateur sports competition

Prevention of cruelty to children or animals

3 To qualify for exemption as a section 501(c)(3) organization, you must:

•

Refrain from supporting or opposing candidates in political campaigns in any way.

•

Ensure that your net earnings do not inure in whole or in part to the benefit of private shareholders or individuals (that is, board members,

officers, key management employees, or other insiders).

•

Not further non-exempt purposes (such as purposes that benefit private interests) more than insubstantially.

•

Not be organized or operated for the primary purpose of conducting a trade or business that is not related to your exempt purpose(s).

•

Not devote more than an insubstantial part of your activities to attempt to influence legislation or, if you made a section 501(h) election, not

normally make expenditures in excess of expenditure limitations outlined in section 501(h).

•

Not engage in activities that are illegal or violate fundamental public policy.

•

Not provide commercial-type insurance as a substantial part of your activities.

Check this box to attest that you have not conducted and will not conduct activities that violate these prohibitions and restrictions.

INTERNAL USE ONLY

4 Do you or will you attempt to influence legislation? .

Yes

(If yes, consider filing Form 5768. See instructions for more details.)

5 Do you or will you pay compensation to any of your officers, directors, or trustees?

(Refer to the instructions for a definition of compensation.) .

Yes

DRAFT AS OF

6 Do you or will you donate funds to or pay expenses for individual(s)?

Yes

7 Do you or will you conduct activities or provide grants or other assistance to individual(s) or organization(s) outside the

United States?

Yes

8 Do you or will you engage in financial transactions (for example, loans, payments, rents, etc.) with any of your officers,

directors, or trustees, or any entities they own or control? .

Yes

February 19, 2014

9 Do you or will you have unrelated business gross income of $1,000 or more during a tax year? .

Yes

10 Do you or will you operate bingo or other gaming activities? .

Yes

11 Do you or will you provide disaster relief?

Yes

Part IV

Foundation Classification

Part IV is designed to classify you as an organization that is either a private foundation or a public charity. Public charity

status is a more favorable tax status than private foundation status.

1 If your organization qualifies for public charity status, check the appropriate box (1a – 1c below) and skip to Part V below.

Check this box to attest that you normally receive at least one-third of your support from public sources or you normally receive at least

10 percent of your support from public sources and you have other characteristics of a publicly supported organization. Sections 509(a)(1)

and 170(b)(1)(A)(vi).

Check this box to attest that you normally receive more than one-third of your support from a combination of gifts, grants, contributions,

membership fees, and gross receipts (from permitted sources) from activities related to your exempt functions and normally receive not

more than one-third of your support from investment income and unrelated business taxable income. Section 509(a)(2).

Check this box to attest that you are operated for the benefit of a college or university that is owned or operated by a governmental unit.

Sections 509(a)(1) and 170(b)(1)(A)(iv).

2 If your organization is not described in items 1a – 1c above, you are a private foundation. As a private foundation, you are required by

section 508(e) to have specific provisions in your organizing document, unless you rely on the operation of state law in the state in which

you were formed to meet these requirements. These specific provisions require that you operate to avoid liability for private foundation

excise taxes under sections 4941-4945.

Check this box to attest that your organizing document contains the provisions required by section 508(e) or that your organizing

document does not need to include the provisions required by section 508(e) because you rely on the operation of state law in your

particular state to meet the requirements of section 508(e). (See the instructions for explanation of the section 508(e) requirements).

Part V

User Fee

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 or print name of signer)

PLEASE

SIGN

HERE

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

(Date)

(Type or print title or authority of signer)

Reminder: Send the completed Form 1023-EZ Checklist with your filled-in application.

1023-EZ

Form

(Rev. 6-2014)