501(c)(3) Services 501(c)(3) Application Initial Questionnaire Responses to the questions below will assist us in determining the type of application form that will be completed on your behalf and also determines our fee for the service. We will contact you after we review your submission. Contact Name * First Last Contact’s Phone Number * Contact’s Email * Non-Profit Organization’s Legal Name * Questions about the Organization 1. Were you formed under the laws of a foreign country? Yes No 2. Is the organization's mailing address in a foreign country Yes No 3. Are you a successor to, or controlled by, or owned by a for-profit entity, or a previously revoked non-profit organization, or an entity suspended under IRC Section 501(p)? Yes No 4. Are you organized as an entity other than a corporation, unincorporated association, or trust? Yes No 5. Were you previously revoked (other than when the tax-exempt status was automatically revoked for failure to file a Form 990-series return for three consecutive years)? Yes No 6. Are you currently recognized as tax exempt under another section of IRC 501(a) or were you previously exempt under another section of IRC 501(a)? Yes No 7. Are you any of the following: church, convention of churches, school/college/university, hospital, cooperative hospital, medical research, HMO (health maintenance organization), or agricultural research organization? Yes No 8. Are you an Accountable Care Organization (ACO), or an organization that engages in, or intends to engage in, ACO activities (such as participation in the Medicare Shared Savings Program (MSSP) or in activities unrelated to the MSSP described in Notice 2011–20, 2011–16 I.R.B. 652)? Yes No 9. Are you organized and operated exclusively for testing for public safety and requesting a foundation classification under IRC Section 509(a)(4)? Yes No 10. Are you applying for exemption as any of the following:<br>- a cooperative service organization of operating educational organizations under IRC Section 501(f);<br>- a cooperative service organization of operating educational organizations under IRC Section 501(f); or<br>- a qualified charitable risk pool under IRC Section 501(n) (i.e., organized and operated only to pool insurable risks of its members)? Yes No 11. Are you requesting classification as a supporting organization under IRC Section 509(a)(3) (i.e., organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of another organization/s)? Yes No 12. Are you requesting classification as a private operating foundation? Yes No 13. Are you applying for reinstatement under section 4 of Rev. Proc. 2014-11, and seeking to change your foundation classification from the classification you had at the time of your revocation? Yes No 14. Are you applying for retroactive reinstatement of exemption under section 5 or 6 of Rev. Proc. 2014-11, after being automatically revoked? Yes No Questions about the organization’s activities 15. Have your annual gross receipts exceeded $50,000 in any of the past 3 years? or do you project that your annual gross receipts will exceed $50,000 in any of the next 3 years? Yes No 16. Do you have total assets the fair market value of which is in excess of $250,000? Yes No 17. Is a substantial purpose of your activities to provide assistance to individuals through credit counseling activities such as budgeting, personal finance, financial literacy, mortgage foreclosure assistance, or other consumer credit areas? Yes No 18. Do you or will you invest 5% or more of your total assets in securities or funds that are not publicly traded? Yes No 19. Do you or will you sell or participate in any:<br>- carbon credits or carbon offsets; or<br>- partnerships (including entities or arrangements treated as partnerships for federal tax purposes) in which you share losses with partners other than section 501(c)(3) organizations? Yes No 20. Do you maintain or intend to maintain one or more donor advised funds? Yes No Comments: Please provide any additional notes or comments to your responses above. Please include reference to which question number the comment refers to. Submit
