"*" indicates required fields 12345 LinkedInThis field is for validation purposes and should be left unchanged.Order Number*Order Date* MM slash DD slash YYYY Part I - Eligibility Requirements and Identification of ApplicantHave your annual gross receipts exceeded $50,000 in any of the past 3 years and/or do you project that your annual gross receipts will exceed $50,000 in any of the next 3 years? If yes, you cannot file the Express Service.* Yes No Do you have total assets the fair market value of which is in excess of $250,000? If yes, you cannot file the Express Service.* Yes No Full Name of Organization*Care Of Name (if applicable)Address* (Street number, name and road. No P.O. boxes.) (Room/suite/etc) City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Employer Identification Number*Month Tax Year Ends*JanFebMarAprMayJunJulAugSeptOctNovDecPerson to Contact (For questions.)*Contact Phone Number*Fax Number (optional)Select the number of officers, directors, and/or trustees.*Main Officer, Director, or Trustee*First NameLast NameTitleStreet AddressCityStateZip code Add RemoveOrganization's Website (if available) Organization's Email (optional) Part II - Organizational StructureTo file this form, you must be a corporation, an unincorporated association, or a trust. Select the option for your organization.* Corporation Unincorporated association Trust Check this box to attest that you have the organizing document necessary for the organizational structure indicated above.* Check this box to attest that you have the organizing document necessary for the organizational structure indicated above. There should not be a 2 in front of that. Date incorporated if a corporation, or formed if other than a corporation (MMDDYYYY)* MM slash DD slash YYYY State of Incorporation or other formation*Select your optionAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificSection 501(c)(3) requires that your organizing document must limit your purposes to one or more exempt purposes within section 501(c)(3).* Check this box to attest that your organizing document contains this limitation. Section 501(c)(3) requires that your organizing document must not expressly empower you to engage, otherwise 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 you to engage, otherwise than as an insubstantial part of your activities, in activities that in themselves are not in furtherance of one or more exempt purposes. Section 501(c)(3) requires that your organizing document must provide that upon dissolution, your remaining assets 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. Part III - Your Specific ActivitiesBriefly describe the organization's mission or most significant activities (limit 250 characters)*Enter the appropriate 3-character NTEE Code that best describes your activities.*NTEE codes can be found here: CLICK HERE 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 To qualify for exemption as a section 501(c)(3) organization, you must:* Check this box to attest that you have not conducted and will not conduct activities that violate these prohibitions and restrictions.• 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 attempting 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 provide commercial-type insurance as a substantial part of your activities. 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 attempting 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 provide commercial-type insurance as a substantial part of your activities.Do you or will you attempt to influence legislation?* Yes No Do you or will you pay compensation to any of your officers, directors, or trustees?* Yes No Do you or will you donate funds to or pay expenses for individual(s)?* Yes No Do you or will you conduct activities or provide grants or other assistance to individual(s) or organization(s) outside the United States?* Yes No 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 No Do you or will you have unrelated business gross income of $1,000 or more during a tax year?* Yes No Do you or will you operate bingo or other gaming activities?* Yes No 12. Do you or will you provide disaster relief?* Yes No 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.Are you applying for recognition as a church, school, or hospital (described in section 170(b)(1)(A)(i), (ii), or (iii) of the Internal Revenue Code)? If yes, you cannot file the Express Service.* Yes No If you qualify for public charity status, check the appropriate box (a - c below).* a. Select 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). b. Select 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). c. Select 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). If you are not described in items a-c 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.* Select 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). Part VI - SignatureI 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.* 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*Date MM slash DD slash YYYY Permissions* Check this box to give permission to S2 Insite to use the information you have provided to file for tax exempt status with the I.R.S. You authorize S2 Insite to be your surrogate regarding your application.
