Form 1024 Application for Recognition of Exemption Under Section 501(a) (Rev. September 1998) OMB No. 1545-0057 If exempt status is approved, this application will be open for public inspection. Department of the Treasury Internal Revenue Service Read the instructions for each Part carefully. A User Fee must be attached to this application. If the required information and appropriate documents are not submitted along with Form 8718 (with payment of the appropriate user fee), the application may be returned to the organization. Complete the Procedural Checklist on page 6 of the instructions. Part I. Identification of Applicant (Must be completed by all applicants; also complete appropriate schedule.) Submit only the schedule that applies to your organization. Do not submit blank schedules. Check the appropriate box below to indicate the section under which the organization is applying: a Section 501(c)(2)—Title holding corporations (Schedule A, page 7) b Section 501(c)(4)—Civic leagues, social welfare organizations (including certain war veterans’ organizations), or local associations of employees (Schedule B, page 8) c Section 501(c)(5)—Labor, agricultural, or horticultural organizations (Schedule C, page 9) d Section 501(c)(6)—Business leagues, chambers of commerce, etc. (Schedule C, page 9) e Section 501(c)(7)—Social clubs (Schedule D, page 11) f Section 501(c)(8)—Fraternal beneficiary societies, etc., providing life, sick, accident, or other benefits to members (Schedule E, page 13) g Section 501(c)(9)—Voluntary employees’ beneficiary associations (Parts I through IV and Schedule F, page 14) h Section 501(c)(10)—Domestic fraternal societies, orders, etc., not providing life, sick, accident, or other benefits (Schedule E, page 13) i Section 501(c)(12)—Benevolent life insurance associations, mutual ditch or irrigation companies, mutual or cooperative telephone companies, or like organizations (Schedule G, page 15) j Section 501(c)(13)—Cemeteries, crematoria, and like corporations (Schedule H, page 16) k Section 501(c)(15)—Mutual insurance companies or associations, other than life or marine (Schedule I, page 17) l Section 501(c)(17)—Trusts providing for the payment of supplemental unemployment compensation benefits (Parts I through IV and Schedule J, page 18) m Section 501(c)(19)—A post, organization, auxiliary unit, etc., of past or present members of the Armed Forces of the United States (Schedule K, page 19) n Section 501(c)(25)—Title holding corporations or trusts (Schedule A, page 7) 1a Full name of organization (as shown in organizing document) 2 Employer identification number (EIN) (if none, see Specific Instructions on page 2) 3 Name and telephone number of person to be contacted if additional information is needed 1b c/o Name (if applicable) 1c Address (number and street) 1d City, town or post office, state, and ZIP + 4 Instructions for Part I, page 2. Room/Suite If you have a foreign address, see Specific ( 1e Web site address 4 Month the annual accounting period ends 5 ) Date incorporated or formed 6 Did the organization previously apply for recognition of exemption under this Code section or under any other section of the Code? If “Yes,” attach an explanation. Yes No 7 Has the organization filed Federal income tax returns or exempt organization information returns? If “Yes,” state the form numbers, years filed, and Internal Revenue office where filed. Yes No 8 Check the box for the type of organization. ATTACH A CONFORMED COPY OF THE CORRESPONDING ORGANIZING DOCUMENTS TO THE APPLICATION BEFORE MAILING. a Corporation— Attach a copy of the Articles of Incorporation (including amendments and restatements) showing approval by the appropriate state official; also attach a copy of the bylaws. b c Trust— Attach a copy of the Trust Indenture or Agreement, including all appropriate signatures and dates. Association— Attach a copy of the Articles of Association, Constitution, or other creating document, with a declaration (see instructions) or other evidence that the organization was formed by adoption of the document by more than one person. Also include a copy of the bylaws. ᮣ If this is a corporation or an unincorporated association that has not yet adopted bylaws, check here 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, including the accompanying schedules and attachments, and to the best of my knowledge it is true, correct, and complete. PLEASE SIGN HERE ᮣ (Signature) For Paperwork Reduction Act Notice, see page 5 of the instructions. (Type or print name and title or authority of signer) (Date) Cat. No. 12343K American LegalNet, Inc. www.FormsWorkFlow.com Form 1024 (Rev. 9-98) Page 2 Part II. Activities and Operational Information (Must be completed by all applicants) 1 Provide a detailed narrative description of all the activities of the organization—past, present, and planned. Do not merely refer to or repeat the language in the organizational document. List each activity separately in the order of importance based on the relative time and other resources devoted to the activity. Indicate the percentage of time for each activity. Each description should include, as a minimum, the following: (a) a detailed description of the activity including its purpose and how each activity furthers your exempt purpose; (b) when the activity was or will be initiated; and (c) where and by whom the activity will be conducted. 2 List the organization’s present and future sources of financial support, beginning with the largest source first. American LegalNet, Inc. www.FormsWorkFlow.com Form 1024 (Rev. 9-98) Page 3 Part II. Activities and Operational Information (continued) 3 Give the following information about the organization’s governing body: a Names, addresses, and titles of officers, directors, trustees, etc. b Annual compensation 4 If the organization is the outgrowth or continuation of any form of predecessor, state the name of each predecessor, the period during which it was in existence, and the reasons for its termination. Submit copies of all papers by which any transfer of assets was effected. 5 If the applicant organization is now, or plans to be, connected in any way with any other organization, describe the other organization and explain the relationship (e.g., financial support on a continuing basis; shared facilities or employees; same officers, directors, or trustees). 6 If the organization has capital stock issued and outstanding, state: (1) class or classes of the stock; (2) number and par value of the shares; (3) consideration for which they were issued; and (4) if any dividends have been paid or whether your organization’s creating instrument authorizes dividend payments on any class of capital stock. 7 State the qualifications necessary for membership in the organization; the classes of membership (with the number of members in each class); and the voting rights and privileges received. If any group or class of persons is required to join, describe the requirement and explain the relationship between those members and members who join voluntarily. Submit copies of any membership solicitation material. Attach sample copies of all types of membership certificates issued. 8 Explain how your organization’s assets will be distributed on dissolution. American LegalNet, Inc. www.FormsWorkFlow.com Form 1024 (Rev. 9-98) Page 4 Part II. Activities and Operational Information (continued) 9 Has the organization made or does it plan to make any distribution of its property or surplus funds to shareholders or members? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No If “Yes,” state the full details, including: (1) amounts or value; (2) source of funds or property distributed or to be distributed; and (3) basis of, and authority for, distribution or planned distribution. 10 Does, or will, any part of your organization’s receipts represent payments for services performed or to be performed? If “Yes,” state in detail the amount received and the character of the services performed or to be performed. 11 Has the organization made, or does it plan to make, any payments to members or shareholders for services performed or to be performed? If “Yes,” state in detail the amount paid, the character of the services, and to whom the payments have been, or will be, made. 12 Does the organization have any arrangement to provide insurance for members, their dependents, or others (including provisions for the payment of sick or death benefits, pensions, or annuities)? If “Yes,” describe and explain the arrangement’s eligibility rules and attach a sample copy of each plan document and each type of policy issued. 13 Is the organization under the supervisory jurisdiction of any public regulatory body, such as a social welfare agency, etc.? If “Yes,” submit copies of all administrative opinions or court decisions regarding this supervision, as well as copies of applications or requests for the opinions or decisions. 14 Does the organization now lease or does it plan to lease any property? If “Yes,” explain in detail. Include the amount of rent, a description of the property, and any relationship between the applicant organization and the other party. Also, attach a copy of any rental or lease agreement. (If the organization is a party, as a lessor, to multiple leases of rental real property under similar lease agreements, please attach a single representative copy of the leases.) 15 Has the organization spent or does it plan to spend any money attempting to influence the selection, nomination, election, or appointment of any person to any Federal, state, or local public office or to an office in a political organization? If “Yes,” explain in detail and list the amounts spent or to be spent in each case. 16 Does the organization publish pamphlets, brochures, newsletters, journals, or similar printed material? If “Yes,” attach a recent copy of each. American LegalNet, Inc. www.FormsWorkFlow.com Form 1024 (Rev. 9-98) Page 5 Part III. Financial Data (Must be completed by all applicants) Complete the financial statements for the current year and for each of the 3 years immediately before it. If in existence less than 4 years, complete the statements for each year in existence. If in existence less than 1 year, also provide proposed budgets for the 2 years following the current year. A. Statement of Revenue and Expenses (a) Current Tax Year Revenue From To 1 Gain from sale of assets, excluding inventory items (attach schedule) 6 Investment income (see page 3 of the instructions) 7 Other revenue (attach schedule) 8 Total revenue (add lines 1 through 7) 9 Expenses attributable to activities related to the organization’s exempt purposes 10 Expenses attributable to unrelated business activities 11 Contributions, gifts, grants, and similar amounts paid (attach schedule) 12 Disbursements to or for the benefit of members (attach schedule) 13 Compensation of officers, directors, and trustees (attach schedule) 14 Other salaries and wages 15 Interest 16 Occupancy 17 Depreciation and depletion 18 Other expenses (attach schedule) 19 Total expenses (add lines 9 through 18) 20 (e) Total Gross amounts from unrelated business activities (attach schedule) 5 (d) Gross amounts derived from activities related to the organization’s exempt purpose (attach schedule) (Include related cost of sales on line 9.) 4 (c) Gross contributions, gifts, etc. 3 (b) Gross dues and assessments of members 2 3 Prior Tax Years or Proposed Budget for Next 2 Years Excess of revenue over expenses (line 8 minus line 19) Expenses B. Balance Sheet (at the end of the period shown) Current Tax Year Assets as of 1 Cash 1 2 Accounts receivable, net 2 3 Inventories 3 4 Bonds and notes receivable (attach schedule) 4 5 Corporate stocks (attach schedule) 5 6 Mortgage loans (attach schedule) 6 7 Other investments (attach schedule) 7 8 Depreciable and depletable assets (attach schedule) 8 9 Land 9 Other assets (attach schedule) 10 10 11 11 Total assets 12 Accounts payable 12 13 Contributions, gifts, grants, etc., payable 13 14 Mortgages and notes payable (attach schedule) 14 15 Other liabilities (attach schedule) 15 Liabilities 16 16 Total liabilities Fund Balances or Net Assets 17 18 Total fund balances or net assets Total liabilities and fund balances or net assets (add line 16 and line 17) 17 18 If there has been any substantial change in any aspect of the organization’s financial activities since the end of the period shown above, ᮣ check the box and attach a detailed explanation American LegalNet, Inc. www.FormsWorkFlow.com Form 1024 (Rev. 9-98) Page 6 Part IV. Notice Requirements (Sections 501(c)(9) and 501(c)(17) Organizations Only) 1 Section 501(c)(9) and 501(c)(17) organizations: Are you filing Form 1024 within 15 months from the end of the month in which the organization was created or formed as required by section 505(c)? Yes No Yes No Yes No Yes No If “Yes,” skip the rest of this Part. If “No,” answer question 2. 2 If you answer “No” to question 1, are you filing Form 1024 within 27 months from the end of the month in which the organization was created or formed? If “Yes,” your organization qualifies under Regulation section 301.9100-2 for an automatic 12-month extension of the 15-month filing requirement. Do not answer questions 3 and 4. If “No,” answer question 3. 3 If you answer “No” to question 2, does the organization wish to request an extension of time to apply under the “reasonable action and good faith” and the “no prejudice to the interest of the government” requirements of Regulations section 301.9100-3? If “Yes,” give the reasons for not filing this application within the 27-month period described in question 2. See Specific Instructions, Part IV, Line 3, page 4, before completing this item. Do not answer question 4. If “No,” answer question 4. 4 If you answer “No” to question 3, your organization’s qualification as a section 501(c)(9) or 501(c)(17) organization can be recognized only from the date this application is filed. Therefore, does the organization want us to consider its application as a request for recognition of exemption as a section 501(c)(9) or 501(c)(17) organization from the date the application is received and not retroactively to the date the organization was created or formed? American LegalNet, Inc. www.FormsWorkFlow.com Form 1024 (Rev. 9-98) Schedule A Page 7 Organizations described in section 501(c)(2) or 501(c)(25) (Title holding corporations or trusts) 1 State the complete name, address, and EIN of each organization for which title to property is held and the number and type of the applicant organization’s stock held by each organization. 2 If the annual excess of revenue over expenses has not been or will not be turned over to the organization for which title to property is held, state the purpose for which the excess is or will be retained by the title holding organization. 3 In the case of a corporation described in section 501(c)(2), state the purpose of the organization for which title to property is held (as shown in its governing instrument) and the Code sections under which it is classified as exempt from tax. If the organization has received a determination or ruling letter recognizing it as exempt from taxation, please attach a copy of the letter. 4 In the case of a corporation or trust described in section 501(c)(25), state the basis whereby each shareholder is described in section 501(c)(25)(C). For each organization described that has received a determination or ruling letter recognizing that organization as exempt from taxation, please attach a copy of the letter. 5 With respect to the activities of the organization. a Yes Is any rent received attributable to personal property leased with real property? No Yes No Yes No If “Yes,” what percentage of the total rent, as reported on the financial statements in Part III, is attributable to personal property? b Will the organization receive income which is incidentally derived from the holding of real property, such as income from operation of a parking lot or from vending machines? If “Yes,” what percentage of the organization’s gross income, as reported on the financial statements in Part III, is incidentally derived from the holding of real property? c Will the organization receive income other than rent from real property or personal property leased with real property or income which is incidentally derived from the holding of real property? If “Yes,” describe the source of the income. Instructions Line 1.—Provide the requested information on each organization for which the applicant organization holds title to property. Also indicate the number and types of shares of the applicant organization’s stock that are held by each. Line 2.—For purposes of this question, “excess of revenue over expenses” is all of the organization’s income for a particular tax year less operating expenses. Line 3.—Give the exempt purpose of each organization that is the basis for its exempt status and the Internal Revenue Code section that describes the organization (as shown in its IRS determination letter). Line 4.—Indicate if the shareholder is one of the following: 1. A qualified pension, profit-sharing, or stock bonus plan that meets the requirements of the Code; 2. A government plan; 3. An organization described in section 501(c)(3); or 4. An organization described in section 501(c)(25). American LegalNet, Inc. www.FormsWorkFlow.com Form 1024 (Rev. 9-98) Schedule B 1 Page 8 Organizations Described in Section 501(c)(4) (Civic leagues, social welfare organizations (including posts, councils, etc., of veterans’ organizations not qualifying or applying for exemption under section 501(c)(19)) or local associations of employees.) Has the Internal Revenue Service previously issued a ruling or determination letter recognizing the applicant organization (or any predecessor organization listed in question 4, Part II of the application) to be exempt under section 501(c)(3) and later revoked that recognition of exemption on the basis that the applicant organization (or its predecessor) was carrying on propaganda or otherwise attempting to influence legislation or on the basis that it engaged in political activity? Yes No Yes No Yes No If “Yes,” indicate the earliest tax year for which recognition of exemption under section 501(c)(3) was revoked and the IRS district office that issued the revocation. 2 Does the organization perform or plan to perform (for members, shareholders, or others) services, such as maintaining the common areas of a condominium; buying food or other items on a cooperative basis; or providing recreational facilities or transportation services, job placement, or other similar undertakings? If “Yes,” explain the activities in detail, including income realized and expenses incurred. Also, explain in detail the nature of the benefits to the general public from these activities. (If the answer to this question is explained in Part II of the application (pages 2, 3, and 4), enter the page and item number here.) 3 If the organization is claiming exemption as a homeowners’ association, is access to any property or facilities it owns or maintains restricted in any way? If “Yes,” explain. 4 If the organization is claiming exemption as a local association of employees, state the name and address of each employer whose employees are eligible for membership in the association. If employees of more than one plant or office of the same employer are eligible for membership, give the address of each plant or office. American LegalNet, Inc. www.FormsWorkFlow.com Form 1024 (Rev. 9-98) Schedule C Page 9 Organizations described in section 501(c)(5) (Labor, agricultural, including fishermen’s organizations, or horticultural organizations) or section 501(c)(6) (business leagues, chambers of commerce, etc.) 1 Describe any services the organization performs for members or others. (If the description of the services is contained in Part II of the application, enter the page and item number here.) 2 Fishermen’s organizations only.—What kinds of aquatic resources (not including mineral) are cultivated or harvested by those eligible for membership in the organization? 3 Labor organizations only.—Is the organization organized under the terms of a collective bargaining agreement? Yes If “Yes,” attach a copy of the latest agreement. American LegalNet, Inc. www.FormsWorkFlow.com No Form 1024 (Rev. 9-98) Schedule D 1 Page 11 Organizations described in section 501(c)(7) (Social clubs) Has the organization entered or does it plan to enter into any contract or agreement for the management or operation of its property and/or activities, such as restaurants, pro shops, lodges, etc.? Yes No Yes No Yes No If “Yes,” attach a copy of the contract or agreement. If one has not yet been drawn up, please explain the organization’s plans. 2 Does the organization seek or plan to seek public patronage of its facilities or activities by advertisement or otherwise? If “Yes,” attach sample copies of the advertisements or other requests. If the organization plans to seek public patronage, please explain the plans. 3a Are nonmembers, other than guests of members, permitted or will they be permitted to use the club facilities or participate in or attend any functions or activities conducted by the organization? If “Yes,” describe the functions or activities in which there has been or will be nonmember participation or admittance. (Submit a copy of the house rules, if any.) b State the amount of nonmember income included in Part III of the application, lines 3 and 4, column (a) c Enter the percent of gross receipts from nonmembers for the use of club facilities d Enter the percent of gross receipts received from investment income and nonmember use of the club’s facilities % % 4a Does the organization’s charter, bylaws, other governing instrument, or any written policy statement of the organization contain any provision that provides for discrimination against any person on the basis of race, color, or religion? Yes b If “Yes,” state whether or not its provision will be kept. c If the organization has such a provision that will be repealed, deleted, or otherwise stricken from its requirements, state when this will be done d If the organization formerly had such a requirement and it no longer applies, give the date it ceased to apply e If the organization restricts its membership to members of a particular religion, check here and attach the explanation specified in the instructions See reverse side for instructions American LegalNet, Inc. www.FormsWorkFlow.com No Form 1024 (Rev. 9-98) Page 12 Instructions Line 1.—Answer “Yes,” if any of the organization’s property or activities will be managed by another organization or company. Lines 3b, c, and d.—Enter the figures for the current year. On an attached schedule, furnish the same information for each of the prior tax years for which you completed Part III of the application. Line 4e.—If the organization restricts its membership to members of a particular religion, the organization must be: 1. An auxiliary of a fraternal beneficiary society that: a. Is described in section 501(c)(8) and exempt from tax under section 501(a), and b. Limits its membership to members of a particular religion; or 2. A club that, in good faith, limits its membership to the members of a particular religion in order to further the teachings or principles of that religion and not to exclude individuals of a particular race or color. If you checked 4e, your explanation must show how the organization meets one of these two requirements. American LegalNet, Inc. www.FormsWorkFlow.com Form 1024 (Rev. 9-98) Schedule E 1 Page 13 Organizations described in section 501(c)(8) or 501(c)(10) (Fraternal societies, orders, or associations) Is the organization a college fraternity or sorority, or chapter of a college fraternity or sorority? Yes No Does or will your organization operate under the lodge system? Yes No If “No,” does or will it operate for the exclusive benefit of the members of an organization operating under the lodge system? Yes No Is the organization a subordinate or local lodge, etc.? Yes No Yes No If “Yes,” read the instructions for Line 1, below, before completing this schedule. 2 3 If “Yes,” attach a certificate signed by the secretary of the parent organization, under the seal of the organization, certifying that the subordinate lodge is a duly constituted body operating under the jurisdiction of the parent body. 4 Is the organization a parent or grand lodge? If “Yes,” attach a schedule for each subordinate lodge in active operation showing: (a) its name and address; (b) the number of members in it; and (c) how often it holds periodic meetings. Instructions Line 1.—To the extent that they qualify for exemption from Federal income tax, college fraternities and sororities generally qualify as organizations described in section 501(c)(7). Therefore, if the organization is a college fraternity or sorority, refer to the discussion of section 501(c)(7) organizations in Pub. 557. If section 501(c)(7) appears to apply to your organization, complete Schedule D instead of this schedule. Line 2.—Operating under the lodge system means carrying on activities under a form of organization that is composed of local branches, chartered by a parent organization, largely self-governing, and called lodges, chapters, or the like. American LegalNet, Inc. www.FormsWorkFlow.com Form 1024 (Rev. 9-98) Schedule F 14 Page Organizations described in section 501(c)(9) (Voluntary employees’ beneficiary associations) 1 Describe the benefits available to members. Include copies of any plan documents that describe such benefits and the terms and conditions of eligibility for each benefit. 2 Are any employees or classes of employees entitled to benefits to which other employees or classes of employees are not entitled? Yes No If “Yes,” explain. 3 Give the following information for each plan as of the last day of the most recent plan year and enter that date here. If there is more than one plan, attach a separate schedule / / (mo.) (day) (yr.) a Total number of persons covered by the plan who are highly compensated individuals (See instructions below.) b Number of other employees covered by the plan c Number of employees not covered by the plan d Total number employed* * Should equal the total of a, b, and c—if not, explain any difference. Describe the eligibility requirements that prevent those employees not covered by the plan from participating. 4 State the number of persons, if any, other than employees and their dependents (e.g., the proprietor of a business whose ᮣ employees are members of the association) who are entitled to receive benefits Instructions Line 3a.—A “highly compensated individual” is one who: (a) Owned 5% or more of the employer at any time during the current year or the preceding year. (b) Received more than $80,000 (adjusted for inflation) in compensation from the employer for the preceding year, and (c) Was among the top 20% of employees by compensation for the preceding year. However, the employer can choose not to have (c) apply. American LegalNet, Inc. www.FormsWorkFlow.com Page 15 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) Form 1024 (Rev. 9-98) 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? 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? 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 should show income received from qualified pole rentals separately. Mutual or cooperative telephone companies should also show separately the gross amount of income received from nonmember telephone companies for performing services that involve their members and the gross amount of income received from the sale of display advertising in a directory furnished to their members. Do not net amounts due or paid to other sources against amounts due or received from those sources. American LegalNet, Inc. www.FormsWorkFlow.com Form 1024 (Rev. 9-98) Schedule H 1 Page 16 Organizations described in section 501(c)(13) (Cemeteries, crematoria, and like corporations) Attach the following documents: a Complete copy of sales contracts or other documents, including any “debt” certificates, involved in acquiring cemetery or crematorium property. b Complete copy of any contract your organization has that designates an agent to sell its cemetery lots. c A copy of the appraisal (obtained from a disinterested and qualified party) of the cemetery property as of the date acquired. 2 Does your organization have, or does it plan to have, a perpetual care fund? Yes No Yes No If “Yes,” attach a copy of the fund agreement and explain the nature of the fund (cash, securities, unsold land, etc.) 3 If your organization is claiming exemption as a perpetual care fund for an organization described in section 501(c)(13), has the cemetery organization, for which funds are held, established exemption under that section? If “No,” explain. American LegalNet, Inc. www.FormsWorkFlow.com Form 1024 (Rev. 9-98) Schedule I 1 Page 17 Organizations described in section 501(c)(15) (Small insurance companies or associations) Is the organization a member of a controlled group of corporations as defined in section 831(b)(2)(B)(ii)? (Disregard section 1563(b)(2)(B) in determining whether the organization is a member of a controlled group.) Yes No If “Yes,” include on lines 2 through 5 the total amount received by the organization and all other members of the controlled group. If “No,” include on lines 2 through 5 only the amounts that relate to the applicant organization. (a) Current Year From To 2 Reinsurance ceded 5 Net written premiums ((line 2 plus line 3) minus line 4) 6 (d) Reinsurance assumed 4 (c) Direct written premiums 3 3 Prior Tax Years (b) If you entered an amount on line 3 or line 4, attach a copy of the reinsurance agreements the organization has entered into. Instructions Line 1.—Answer “Yes,” if the organization would be considered a member of a controlled group of corporations if it were not exempt from tax under section 501(a). In applying section 1563(a), use a “more than 50%” stock ownership test to determine whether the applicant or any other corporation is a member of a controlled group. Line 2.— In addition to other direct written premiums, include on line 2 the full amount of any prepaid or advance premium in the year the prepayment is received. For example, if a $5,000 premium for a 3-year policy was received in the current year, include the full $5,000 amount in the Current Year column. American LegalNet, Inc. www.FormsWorkFlow.com Form 1024 (Rev. 9-98) Schedule J Page 18 Organizations described in section 501(c)(17) (Trusts providing for the payment of supplemental unemployment compensation benefits) 1 If benefits are provided for individual proprietors, partners, or self-employed persons under the plan, explain in detail. 2 If the plan provides other benefits in addition to the supplemental unemployment compensation benefits, explain in detail and state whether the other benefits are subordinate to the unemployment benefits. 3 Give the following information as of the last day of the most recent plan year and enter that date here a Total number of employees covered by the plan who are shareholders, officers, self-employed persons, or highly compensated (See Schedule F instructions for line 3a on page 14.) b Number of other employees covered by the plan c Number of employees not covered by the plan d Total number employed* * Should equal the total of a, b, and c—if not, explain the difference. Describe the eligibility requirements that prevent those employees not covered by the plan from participating. 4 At any time after December 31, 1959, did any of the following persons engage in any of the transactions listed below with the trust: the creator of the trust or a contributor to the trust; a brother or sister (whole or half blood), a spouse, an ancestor, or a lineal descendant of such a creator or contributor; or a corporation controlled directly or indirectly by such a creator or contributor? Note: If you know that the organization will be, or is considering being, a party to any of the transactions (or activities) listed below, check the “Planned” box. Give a detailed explanation of any “Yes” or “Planned” answer in the space below. a Borrow any part of the trust’s income or corpus? Yes No Planned b Receive any compensation for personal services? Yes No Planned c Obtain any part of the trust’s services? Yes No Planned d Purchase any securities or other properties from the trust? Yes No Planned e Sell any securities or other property to the trust? Yes No Planned f Receive any of the trust’s income or corpus in any other transaction? Yes No Planned 5 Attach a copy of the Supplemental Unemployment Benefit Plan and related agreements. American LegalNet, Inc. www.FormsWorkFlow.com Form 1024 (Rev. 9-98) Schedule K 1 Page 19 Organizations described in section 501(c)(19)—A post or organization of past or present members of the Armed Forces of the United States, auxiliary units or societies for such a post or organization, and trusts or foundations formed for the benefit of such posts or organizations. To be completed by a post or organization of past or present members of the Armed Forces of the United States. a Total membership of the post or organization b Number of members who are present or former members of the U.S. Armed Forces c Number of members who are cadets (include students in college or university ROTC programs or at armed services academies only), or spouses, widows, or widowers of cadets or past or present members of the U.S. Armed Forces d Does the organization have a membership category other than the ones set out above? Yes No Yes No Yes No Yes No Yes No If “Yes,” please explain in full. Enter number of members in this category e If you wish to apply for a determination that contributions to your organization are deductible by donors, enter the number of members from line 1b who are war veterans, as defined below A war veteran is a person who served in the Armed Forces of the United States during the following periods of war: April 21, 1898, through July 4, 1902; April 6, 1917, through November 11, 1918; December 7, 1941, through December 31, 1946; June 27, 1950, through January 31, 1955; and August 5, 1964, through May 7, 1975. 2 To be completed by an auxiliary unit or society of a post or organization of past or present members of the Armed Forces of the United States. a Is the organization affiliated with and organized according to the bylaws and regulations formulated by such an exempt post or organization? If “Yes,” submit a copy of such bylaws or regulations. b How many members does your organization have? c How many are themselves past or present members of the Armed Forces of the United States, or are their spouses, or persons related to them within two degrees of blood relationship? (Grandparents, brothers, sisters, and grandchildren are the most distant relationships allowable.) d Are all of the members themselves members of a post or organization, past or present members of the Armed Forces of the United States, spouses of members of such a post or organization, or related to members of such a post or organization within two degrees of blood relationship? 3 To be completed by a trust or foundation organized for the benefit of an exempt post or organization of past or present members of the Armed Forces of the United States. a Will the corpus or income be used solely for the funding of such an exempt organization (including necessary related expenses)? If “No,” please explain. b If the trust or foundation is formed for charitable purposes, does the organizational document contain a proper dissolution provision as described in section 1.501(c)(3)-1(b)(4) of the Income Tax Regulations? American LegalNet, Inc. www.FormsWorkFlow.com Procedural Checklist Make sure the application is complete. If you do not complete all applicable parts or do not provide all required attachments, we may return the incomplete application for the organization to resubmit with the missing information or attachments. This will delay the processing of the application and may delay the effective date of your organization’s exempt status. The organization may also incur additional user fees. Have you . . . Attached Form 8718 (User Fee for Exempt Organization Determination Letter Request) and the appropriate fee? Prepared the application for mailing? (See Where To File addresses in Form 8718.) Completed all Parts and Schedules that apply to the organization? Shown your organization’s Employer Identification Number (EIN)? a. If your organization has an EIN, write it in the space provided. b. If this is a newly formed organization and does not have an Employer Identification Number, obtain an EIN by telephone. (See Specific Instructions, Part I, Line 2, on page 2.) If applicable, described your organization’s specific activities as directed in Part II, question 1 of the application? Included a conformed copy of the complete organizing instrument? (Part I, question 8 of the application.) Had the application signed by one of the following: a. An officer or trustee who is authorized to sign (e.g., president, treasurer); or b. A person authorized by a power of attorney (submit Form 2848 or other power of attorney)? If applicable, enclosed financial statements (Part III)? a. Current year (must include period up to within 60 days of the date the application is filed) and 3 preceding years. b. Detailed breakdown of revenue and expenses (no lump sums). c. If the organization has been in existence less than 1 year, it must also submit proposed budgets for 2 years showing the amounts and types of receipts and expenditures anticipated. Note: Dur ing the technical review of a completed application, it may be necessary to contact the organization for more specific or additional information. Do not send this checklist with the application. Page 6 American LegalNet, Inc. www.FormsWorkFlow.com