8940 Request for Miscellaneous Determination

Form

8940

(Rev. April 2023)
Department of the Treasury
Internal Revenue Service

Request for Miscellaneous Determination

OMB No. 1545-0047

Do not enter social security numbers on this form as it may be made public.
Go to www.irs.gov/Form8940 for instructions and the latest information.

Note: If your request is
approved, the information
you provide may be open for
public inspection.

Use the "?" buttons throughout this form for help in completing your request. For additional help, call IRS Exempt Organizations Customer Account Services tollfree at 877-829-5500.
If you cannot complete required responses within the textbox limits throughout this form, upload your additional narratives with the other required documents.

Part I

Identification of Applicant

1

Full Name of Organization (exactly as it appears in your organizing document)

2

Care of Name (if applicable)

3

Mailing Address (number, street and room/suite)

4 City

6

State

7 Zip Code + 4

10 Employer Identification Number

5 Country

United States

8 Foreign Province (or State)

11 Month Tax Year Ends

13 Contact Telephone Number

9 Foreign Postal Code

12 Person to Contact if More Information is Needed (officer,
director, trustee, or authorized representative)

14 Fax Number (optional)

15 User Fee Submitted

$0.00

16 Organization's Website (if available):
17 List the names, titles, and mailing addresses of your officers, directors, and/or trustees.
First Name:

Last Name:

Mailing Address:
State (or Province):
First Name:

Zip Code (or Foreign Postal Code):
Last Name:

Mailing Address:

Zip Code (or Foreign Postal Code):
Last Name:

Mailing Address:

Zip Code (or Foreign Postal Code):
Last Name:

Mailing Address:

Title:
City:

State (or Province):
First Name:

Title:
City:

State (or Province):
First Name:

Title:
City:

State (or Province):
First Name:

Title:
City:

Zip Code (or Foreign Postal Code):
Last Name:

Mailing Address:
State (or Province):

Title:
City:
Zip Code (or Foreign Postal Code):

Check here to add more officers, directors, and/or trustees.

For Paperwork Reduction Act Notice, see instructions.

Catalog No. 12343K

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Part II
1

Name:

EIN:

Page 2

Type of Request (See Instructions for attachments to upload with your particular request)

Select the item below that best describes your request.
Advance approval of certain set-asides described in section 4942(g)(2) (Schedule A)
Advance approval of voter registration activities described in section 4945(f) (Schedule B)
Advance approval of scholarship procedures described in section 4945(g) (Schedule C)
Exception from Form 990 filing requirements (Schedule D)
Advance approval that a potential grant or contribution constitutes an "unusual grant" (Schedule E)
Change in Type (or initial determination of Type) of a section 509(a)(3) organization (Schedule F)
Reclassification of foundation status, including a voluntary request from a public charity for private foundation status (Schedule G)
Termination of private foundation status under section 507(b)(1)(B)—advance ruling request (Schedule H)
Notice Only - Termination of private foundation status under section 507(b)(1)(B) (Schedule I)
Termination of private foundation status under section 507(b)(1)(B)—60-month period ended (Schedule J)
Voluntary termination of section 501(c)(3) recognition by a Government Entity (See Instructions)
Canadian registered charities: listing on Pub. 78 Data and/or public charity classification (Schedule K)

Part III
1

Explanation of Request

Provide a detailed description of your request.

Part IV

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 name of signer)

(Type title or authority of signer)

11/04/2025
(Date)

Form 8940 (Rev. 04-2023)

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Upload checklist
General:
Organizing document (and any amendments) (if applicable)
Bylaws (if applicable)
Form 2848, Power of Attorney and Declaration of Representative (if applicable)
Form 8821, Tax Information Authorization (if applicable)
Supplemental responses (if applicable)
Expedited handling request (if applicable)
Advance approval of certain set-asides described in section 4942(g)(2) - contingency set-aside:
A copy of the court order restricting you from distributing assets or income
Exception from Form 990 filing requirements as a state institution (other than a section 509(a)(3) supporting organization) whose
income is excluded from gross income under section 115:
A copy of the ruling letter from the IRS stating that your income, derived from activities constituting the basis for your exemption under
section 501(c), is excluded from gross income under section 115
Exception from Form 990 filing requirements as an organization described in section 501(c)(1):
A copy of your determination letter or other documentation from the IRS that indicates whether you are described in section 501(c)(1).
Reclassification of foundation status or termination of private foundation status as a public charity described under sections
509(a)(1) and 170(b)(1)(A)(iv), 509(a)(1) and 170(b)(1)(A)(vi), or 509(a)(2):
Schedule A (Form 990 or 990-EZ), Part II or III (as applicable)
Request for reclassification as a private operating foundation, as described in section 4942(j)(3) or as an exempt operating
foundation, as described in section 4940(d)(2):
Form 990-PF, Part XIII - Private Operating Foundations
Termination of private foundation status under section 507(b)(1)(B)—advance ruling:
Form 872-B, Consent to Extend the Time to Assess Miscellaneous Excise Taxes
Canadian registered charities:
Notification of Registration from the Canada Revenue Agency
Form 8833, Treaty-Based Return Position Disclosure Under Section 6114 or 7701(b)

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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Schedule A. Advance approval of certain set-asides described in section 4942(g)(2)
1

Select your type of set-aside request below.
Suitability test set-aside (continue to Line 2)
Contingent set-aside (private foundations only) Note: at the end of this form, upload a copy of the court order restricting you from
distributing assets or income.

1a

State the amount of the set-aside held pursuant to the court order that otherwise would be distributed as qualifying
distributions.

1b

Will the amount set aside actually be paid by the last day of your tax year after your tax year in which the litigation
is terminated? If "No," explain. Do not complete the rest of Schedule A.

2

Describe the nature and purposes of the specific project and the amount of the set-aside.

3

Describe the amounts and dates of planned additions to the set-aside after its initial establishment, if applicable.

4

Explain why the project can be better accomplished by a set-aside rather than an immediate payment of funds.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

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Schedule A. Advance approval of certain set-asides described in section 4942(g)(2) (continued)
5

Describe the project. Include estimated costs, sources of any future funds expected to be used to complete the project, and location of any
physical facilities to be acquired or constructed as part of the project.

6

Will the amounts to be set aside actually be paid within a specified period of time that ends not more than 60
months after the date of the first set-aside? If "Yes," continue to Line 7.

6a

State the extension of time beyond the 60-month period you require to actually pay the set aside amounts. Explain why the 60-month
period should be extended.

6b

Explain why the proposed project could not be divided into two or more projects covering periods of no more than 60 months each.

7

Are you described under section 509(a)(3) as a non-functionally integrated Type III supporting organization? If
"No," do not complete the rest of Schedule A.

Yes

No

7a

Have you obtained a written statement from each supported organization whose exempt purposes the specific
project accomplishes, signed under penalty of perjury by one of the supported organization's principal officers,
stating that the supported organization approves the project as one that accomplishes one or more of the
supported organization's exempt purposes and also approves the supported organization's determination that the
project is one that can be better accomplished by such a set-aside than by the immediate payment of funds?

Yes

No

7b

Explain how you meet the responsiveness test under Regulations section 1.509(a)-4(i)(3) with respect to a supported organization whose
exempt purposes are accomplished by the specific project.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

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Schedule B. Advance approval of voter registration activities described in section 4945(f)
1

Are you described in section 501(c)(3) and exempt from taxation under section 501(a)?

2

Describe how your voter registration activities are nonpartisan.

3

Yes

No

Are your voter registration activities confined to one specific election period?

Yes

No

4

Are your voter registration activities carried out in five or more states?

Yes

No

5

Do you spend at least 85% of your income directly for the active conduct of activities constituting the purpose or
function for which you are organized and operated?

Yes

No

6

Do you receive at least 85% of your support (other than section 509(e) gross investment income) from exempt
organizations, the general public, governmental units described in section 170(c)(1), or any combination of those?

Yes

No

7

Do you receive more than 25% of your support (other than gross investment income) from any one exempt
organization?

Yes

No

8

Do you receive more than 50% of your support from gross investment income?

Yes

No

9

Are contributions to you for voter registration drives subject to conditions that they may be used only in specified
States, possessions of the United States, or political subdivisions or other areas of any of the foregoing, or the
District of Columbia, or that they may be used in only one specific election period? If "Yes," explain.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

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Schedule C. Advance approval of scholarship procedures described in section 4945(g)
1

Check the box(es) indicating under which section(s) you want your grant making procedures to be considered.
4945(g)(1) - Scholarship or fellowship grant to an individual for study at an educational institution
4945(g)(3) - Other grants, including loans, to an individual for travel, study, or other similar purposes, to enhance a particular skill of
the grantee or to produce a specific product

2

Describe the types of educational grants you provide to individuals, such as scholarships, fellowships, loans, etc., including the purpose,
number and amount(s) of grants, how the program is publicized, and if you award educational loans, the terms of the loans.

3

Do you maintain case histories showing recipients of your scholarships, fellowships, educational loans, or other
educational grants, including names, addresses, purposes of awards, amount of each grant, manner of selection,
and relationship (if any) to officers, trustees, or donors of funds to you? If "No," explain.

4

Describe the specific criteria you use to determine who is eligible for your program (for example, eligibility selection criteria could consist of
graduating high school students from a particular high school who will attend college, writers of scholarly works about American history,
etc.).

5

Describe the specific criteria you use to select recipients (for example, specific selection criteria could consist of prior academic
performance, financial need, etc.).

Yes

No

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Schedule C. Advance approval of scholarship procedures described in section 4945(g) (continued)
6

Describe any requirement or condition you impose on recipients to obtain, maintain, or qualify for renewal of a grant (for example, specific
requirements or conditions could consist of attendance at a four-year college, maintaining a certain grade point average, teaching in public
school after graduation from college, etc.).

7

Describe your procedures for supervising the scholarships, fellowships, educational loans, or other educational grants. Explain whether you
obtain reports and grade transcripts from recipients, or you pay grants directly to a school under an arrangement whereby the school will
apply the grant funds only for enrolled students who are in good standing. Also, describe your procedures for taking action if the terms of
the award are violated.

8

How do you determine who is on the selection committee for the awards made under your program?

9

Are relatives of members of the selection committee, or of your officers, directors, or substantial contributors eligible
for awards made under your program? If "Yes," what measures do you take to ensure unbiased selections and that
awards are not provided to disqualified persons?

Yes

No

Note: As a private foundation, you are not permitted to provide educational grants to disqualified persons. Disqualified persons include your
substantial contributors, foundation managers and certain family members of disqualified persons.

Form 8940 (Rev. 04-2023)

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Schedule C. Advance approval of scholarship procedures described in section 4945(g) (continued)
10

Do you represent that you will (1) arrange to receive and review grantee reports annually and upon completion of the
purpose for which the grant was awarded, (2) investigate diversions of funds from their intended purposes, and (3)
take all reasonable and appropriate steps to recover diverted funds, ensure other grant funds held by a grantee are
used for their intended purposes, and withhold further payments to grantees until you obtain grantees' assurances
that future diversions will not occur and that grantees will take extraordinary precautions to prevent future diversions
from occurring?

Yes

No

11

Do you represent that you will maintain all records relating to individual grants, including information obtained to
evaluate grantees, identify whether a grantee is a disqualified person, establish the amount and purpose of each
grant, and establish that you undertook the supervision and investigation of grants described in Line 10?

Yes

No

12

Do you or will you award scholarships, fellowships, and educational loans to attend an educational institution based
on the status of an individual being an employee of a particular employer? If "No," do not complete the rest of
Schedule C.

Yes

No

13

Will you comply with the seven conditions and either the percentage tests or facts and circumstances test for
scholarships, fellowships, and educational loans to attend an educational institution as set forth in Revenue
Procedures 76-47, 1976-2 C.B. 670, and 80-39, 1980-2 C.B. 772, which apply to inducement, selection committee,
eligibility requirements, objective basis of selection, employment, course of study, and other objectives?

Yes

No

14

Do you or will you provide scholarships, fellowships, or educational loans to attend an educational institution to
employees of a particular employer? If "No," continue to Line 15.

Yes

No

14a Will you award grants to 10% or fewer of the eligible applicants who were actually considered by the selection
committee in selecting recipients of grants in that year as provided by Revenue Procedures 76-47 and 80-39?

Yes

No

15

Yes

No

15a Will you award grants to 25% or fewer of the eligible applicants who were actually considered by the selection
committee in selecting recipients of grants in that year as provided by Revenue Procedures 76-47 and 80-39? If
"Yes," do not complete the rest of Schedule C.

Yes

No

15b Will you award grants to 10% or fewer of the number of employees' children who can be shown to be eligible for
grants (whether or not they submitted an application) in that year, as provided by Revenue Procedures 76-47 and
80-39? If "Yes," describe how you will determine who can be shown to be eligible for grants without submitting an
application, such as by obtaining written statements or other information about the expectations of employees'
children to attend an educational institution; do not complete the rest of Schedule C.

Yes

No

15c Will you award grants based on facts and circumstances that demonstrate that the grants will not be considered
compensation for past, present, or future services or otherwise provide a significant benefit to the particular
employer? If "Yes," describe the facts and circumstances you believe will demonstrate that the grants are neither
compensatory nor a significant benefit to the particular employer. In your explanation, describe why you cannot
satisfy either the 25% test or the 10% test in questions 15a and 15b.

Yes

No

Do you provide scholarships, fellowships, or educational loans to attend an educational institution to children of
employees of a particular employer? If "No," do not complete the rest of Schedule C.

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

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Schedule D. Exception from Form 990 filing requirements
1

Select which filing exception you are requesting from the list below.
A church, an interchurch organization of local units of a church, a convention or association of churches (Schedule L)
An integrated auxiliary of a church described in Regulations section 1.6033-2(h) (such as a men's or women's organization, seminary,
mission society, or youth group) or a school below college level affiliated with a church or operated by a religious order (Section 1)
A church-affiliated organization (other than a section 509(a)(3) organization) that is exclusively engaged in managing funds or
maintaining retirement programs and is described in Revenue Procedure 96-10, 1996-1 C.B. 577 (Section 2)
A mission society (other than a section 509(a)(3) supporting organization) sponsored by, or affiliated with, one or more churches or
church denominations, if more than half of the society's activities are conducted in, or directed at, persons in foreign countries (Section
3)
A state institution (other than a section 509(a)(3) supporting organization) whose income is excluded from gross income under section
115 (See Instructions)
A governmental unit or an affiliate of a governmental unit (other than a section 509(a)(3) supporting organization) described in
Revenue Procedure 95-48, 1995-2 C.B. 418 (Section 4)
An organization described in section 501(c)(1) (See Instructions)

Section 1
1

An integrated auxiliary of a church described in Regulations section 1.6033-2(h) (such as a men's or women's
organization, seminary, mission society, or youth group) or a school below college level affiliated with a church or
operated by a religious order
Are you described both in sections 501(c)(3) and 509(a)(1), (2), or (3)?
Yes

No

2

Are you an educational organization below college level described in sections 509(a)(1) and 170(b)(1)(A)(ii) with a
program of general academic nature and operated by a religious order? If "Yes," explain and do not complete the
rest of Schedule D.

Yes

No

3

Are you covered by a group exemption letter issued to a church or convention or association of churches under the
applicable administrative procedures? If "Yes," provide the name and Group Exemption Number (GEN) of the
church or convention or association of churches that is the central organization in the group exemption and continue
to Line 4.

Yes

No

Form 8940 (Rev. 04-2023)

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Schedule D. Exception from Form 990 filing requirements (continued)
Section 1
3a

3b

An integrated auxiliary of a church described in Regulations section 1.6033-2(h) (such as a men's or women's
organization, seminary, mission society, or youth group) or a school below college level affiliated with a church or
operated by a religious order (continued)
Are you operated, supervised, or controlled by or in connection with a church or convention or association of
Yes
churches (as defined in Regulations section 1.509(a)-4)? If "Yes," describe how you are operated, supervised, or
controlled by or in connection with a church or a convention or association of churches within the meaning of
Regulations section 1.509(a)-4 and continue to Line 4.

No

Do facts and circumstances show that you are affiliated with a church or convention or association of churches? If
"Yes," check the box(es) below for each affiliation factor that is present and explain how it is present.

No

Yes

You share common religious doctrines, principles, disciplines, or practices with a church or a convention or association of churches
according to your corporate charter, trust instrument, articles of association, constitution, bylaws or similar document.
A church or convention or association of churches has the authority to control the appointment or removal of at least one of your
officers or directors.
Your corporate name shows an institutional relationship with a church or a convention or association of churches.
You report your financial and general operations to a church or a convention or association of churches at least annually.
You and the church or convention or association of churches have an institutional relationship that is affirmed by the church or
convention or association of churches, or a designee thereof.
If you were to dissolve, your assets are required to be distributed to a church or a convention or association of churches or to an
affiliate, within the meaning of Regulations section 1.6033-2(h).
Other relevant facts and circumstances not listed above that demonstrate your affiliation.

4

Are you a men's or women's organization, seminary, mission society, or youth group? If "Yes," do not complete the
rest of Schedule D.

Yes

No

5

Are you a school below college level (as described in sections 509(a)(1) and 170(b)(1)(A)(ii))? If "Yes," do not
complete the rest of Schedule D.

Yes

No

Form 8940 (Rev. 04-2023)

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Schedule D. Exception from Form 990 filing requirements (continued)
Section 1
6

An integrated auxiliary of a church described in Regulations section 1.6033-2(h) (such as a men's or women's
organization, seminary, mission society, or youth group) or a school below college level affiliated with a church or
operated by a religious order (continued)
Are you internally supported? If "No," explain and do not complete the rest of Schedule D.
Yes

No

6a

Do you offer admissions, goods, services, or facilities for sale, other than on an incidental basis, to the general public
(except goods, services, or facilities sold at a nominal charge or for an insubstantial portion of the cost)? If "Yes,"
explain.

Yes

No

6b

Do you normally receive more than 50% of your support from a combination of: government sources, public
solicitation of contributions, or receipts from the sale of admissions, goods, performance of services, or furnishing of
facilities in activities that are not unrelated trades or businesses? If "Yes," explain.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

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Schedule D. Exception from Form 990 filing requirements (continued)
Section 2
1

A church-affiliated organization (other than a section 509(a)(3) organization) that is exclusively engaged in managing
funds or maintaining retirement programs and is described in Revenue Procedure 96-10, 1996-1 C.B. 577
Are you described in section 501(c)(3) and under either section 509(a)(1) or 509(a)(2)?
Yes
No

2

Are you operated, supervised, or controlled by one or more churches, integrated auxiliaries, or conventions or
associations of churches? If "Yes," describe how you are operated, supervised, or controlled by one or more churchaffiliated organizations. If "No," continue to line 3.

Yes

No

2a

Are you engaged exclusively in financing, funding the activities of, or managing the funds of a church, integrated
auxiliary, or convention or association of churches? If "Yes," explain and do not complete the rest of Schedule D.

Yes

No

2b

Are you engaged exclusively in financing, funding the activities of, or managing the funds of a group of organizations
substantially all of which are described in sections 509(a)(1) and 170(b)(1)(a)(i), if substantially all of your assets are
provided by, or held for the benefit of, those organizations? If "Yes," explain and do not complete the rest of
Schedule D.

Yes

No

2c

Do you maintain retirement insurance programs primarily for organizations described in sections 509(a)(1) and
170(b)(1)(a)(i) and more than 50% of the individuals covered by the programs are directly employed by those
organizations? If "Yes," explain and do not complete the rest of Schedule D.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

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Schedule D. Exception from Form 990 filing requirements (continued)
Section 2
2d

3

A church-affiliated organization (other than a section 509(a)(3) organization) that is exclusively engaged in managing
funds or maintaining retirement programs and is described in Revenue Procedure 96-10, 1996-1 C.B. 577 (continued)
Do you maintain retirement insurance programs primarily for organizations described in sections 509(a)(1) and
Yes
No
170(b)(1)(a)(i) and more than 50% of the assets are contributed by, or held for the benefit of, employees of those
organizations? If "Yes," explain and do not complete the rest of Schedule D.

Are you operated, supervised, or controlled by one or more religious orders and engaged in financing, funding, or
managing assets used for exclusively religious activities? If "Yes," explain.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

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Schedule D. Exception from Form 990 filing requirements (continued)
Section 3
1

A mission society (other than a section 509(a)(3) supporting organization) sponsored by, or affiliated with, one or more
churches or church denominations, if more than half of the society's activities are conducted in or directed at persons in
foreign countries
Are you described in section 501(c)(3) and under either section 509(a)(1) or 509(a)(2)?
Yes
No

2

Are more than half of your activities conducted in or directed at persons in foreign countries? Explain.

Yes

No

3

Do facts and circumstances show that you are sponsored by or affiliated with one or more churches or church
denominations? Check the box(es) below for each factor that is present and explain how it is present.

Yes

No

You share common religious doctrines, principles, disciplines, or practices with a church or a convention or association of churches
according to your corporate charter, trust instrument, articles of association, constitution, bylaws or similar document.
A church or convention or association of churches has the authority to control the appointment or removal of at least one of your
officers or directors.
Your corporate name shows an institutional relationship with a church or a convention or association of churches.
You report your financial and general operations to a church or a convention or association of churches at least annually.
You and the church or convention or association of churches have an institutional relationship that is affirmed by the church or
convention or association of churches, or a designee thereof.
If you were to dissolve, your assets are required to be distributed to a church or a convention or association of churches or to an
affiliate, within the meaning of Regulations section 1.6033-2(h).
Other relevant facts and circumstances not listed above that demonstrate your sponsorship or affiliation.

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

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Schedule D. Exception from Form 990 filing requirements (continued)
Section 4
1

A governmental unit or an affiliate of a governmental unit (other than a section 509(a)(3) supporting organization)
described in Revenue Procedure 95-48, 1995-2 C.B. 418
Are you described under section 501(a) but not under section 509(a)(3)?
Yes

No

2

Are you a governmental unit because you meet one of the following definitions:

No

Yes

a. A State or local governmental unit as defined in Regulations section 1.103-1(b), which includes a State, territory, a possession of
the United States, the District of Columbia, or any political subdivision thereof;
b. An organization entitled to receive deductible charitable contributions as an organization described in section 170(c)(1), which is a
State, territory, a possession of the United States, or any political subdivision of any of the foregoing, or the United States or the
District of Columbia, but only if the contribution or gift is made for exclusively public purposes; or
c. An Indian tribal government or a political subdivision thereof under sections 7701(a)(40) and 7871?
If "Yes," explain and do not complete the rest of Schedule D.

3

Are you an affiliate of a governmental unit because you have a ruling or determination letter from the Service that:

Yes

No

a. Your income is excluded from gross income under section 115;
b. You are entitled to receive deductible contributions under section 170(c)(1); or
c. You are a wholly owned instrumentality of a state or political subdivision thereof for employment tax purposes (see sections
3121(b)(7) and 3306(c)(7))?
If "Yes," at the end of this form, upload a copy of your ruling or determination letter and do not complete the rest of Schedule D.
4

Are the members of your governing body elected by the public at large, pursuant to local statute or ordinance; or are
a majority of the members of your governing body appointed by governmental units or by organizations that are
affiliates of governmental units (within the meaning of Regulations section 1.509(a)-4(g)(1)(i))? If "Yes," explain. If
“No,” do not complete the rest of Schedule D.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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Schedule D. Exception from Form 990 filing requirements (continued)
Section 4
4a

A governmental unit or an affiliate of a governmental unit (other than a section 509(a)(3) supporting organization)
described in Revenue Procedure 95-48, 1995-2 C.B. 418 (continued)
Do you satisfy at least two of the following five affiliation factors? If "Yes," check the boxes below and explain
Yes
(including references from your articles, bylaws, etc.).

No

You were created by one or more governmental units, affiliates of governmental units, or public officials acting in their official capacity.
You receive your support principally from taxes, tolls, fines, government appropriations, or fees collected pursuant to statutory
authority. Amounts received as government grants or other contract payments are not qualifying support.
You are financially accountable to one or more governmental units. This factor is present if you are (1) required to report to
governmental unit(s), at least annually, information comparable to that required by Form 990, and (2) subject to financial audit by the
governmental unit(s) to which you report. A report submitted voluntarily by you does not satisfy this provision. Also, reports and audits
pursuant to government grants or other contracts do not satisfy this provision.
One or more governmental units, or affiliates of governmental units, exercise control over, or oversee, some or all of your expenditures
(although you are not financially accountable to governmental units).
If you are dissolved, your assets will (by reason of a provision in your articles of organization or by operation of law) be distributed to
one or more governmental units or affiliates of governmental units.

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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Schedule E. Advance approval that a potential grant or contribution constitutes an "unusual grant"
1

Are you described in section 501(c)(3) and either sections 509(a)(1) and 170(b)(1)(A)(vi) or 509(a)(2)?

Yes

No

2

Were you selected for the grant because of your publicly supported nature? If "Yes," explain.

Yes

No

3

Is the amount of the grant unusual or unexpected? If "Yes," explain.

Yes

No

4

Would the grant, due to its size, adversely affect your status as a publicly supported organization? If "Yes," explain.

Yes

No

5

Provide the name of the grantor, the amount of the grant, when you expect to receive the grant, and the purpose(s) for which you will use
the grant funds.

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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Schedule E. Advance approval that a potential grant or contribution constitutes an "unusual grant" (continued)
6

Was the contribution made by any person (or persons standing in a relationship to such person which is described in
sections 4946(a)(1)(C) through (G)) who created you, previously contributed a substantial amount of your support or
endowment, or stood in a position of authority, such as a foundation manager (within the meaning of section
4946(b)), with respect to you? If "Yes," explain.

Yes

No

7

Does the contributor or any person standing in a relationship to such contributor which is described in sections
4946(a)(1)(C) through (G) continue to directly or indirectly exercise control over you? If "Yes," explain.

Yes

No

8

Was the contribution:
a bequest or
an inter vivos transfer (a transfer or gift during one's lifetime)?

9

Describe the form or format of the expected grant (for example, is the grant cash, readily marketable securities, or assets which further
your exempt purposes).

10

Describe your public solicitation programs, including how much public support you received from these efforts.

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

Page 20

EIN:

Schedule E. Advance approval that a potential grant or contribution constitutes an "unusual grant" (continued)
11

Describe how you expect to attract public support following this contribution.

12

Prior to the contribution, were you able to meet your applicable public support test without the benefit of any
exclusions of unusual grants? Explain.

Yes

No

13

Do you have a representative governing body which is comprised of public officials, or individuals chosen by public
officials acting in their capacity as such; of persons having special knowledge in the particular field or discipline in
which you operate; of community leaders, such as elected officials, clergymen, and educators; or, if you are a
membership organization, of individuals elected pursuant to your governing instrument or bylaws by a broadly based
membership? If "Yes," explain.

Yes

No

14

Have any material restrictions or conditions (within the meaning of Regulations section 1.507-2(a)(7)) been imposed
on you by the transferor in connection with this contribution? If "Yes," explain.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

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Schedule F. Section 509(a)(3) Supporting Organizations
1

Are you a nonexempt charitable trust described in section 4947(a)(1) requesting an initial determination that you are
described in section 509(a)(3)? If "No," continue to Line 2.

1a

Provide a list of all of the trustees that have served, together with a statement stating whether such trustees were disqualified persons
within the meaning of section 4946(a) (other than as foundation managers). At the end of this form, upload a copy of your original trust
instrument and all amendments adopted thereafter.

2

List the names, addresses, and EINs of the organizations you support.

3

Do you engage solely in activities that support or benefit your supported organizations? If "Yes," describe these
activities.

Yes

No

4

Are all your supported organizations public charities under section 509(a)(1) or (2)? If "Yes," continue to Line 5.

Yes

No

4a

Are your supported organizations tax exempt under section 501(c)(4), 501(c)(5), or 501(c)(6) and do your supported
organizations meet the public support test under section 509(a)(2)? If "No," explain how each organization you
support is a public charity under section 509(a)(1) or 509(a)(2).

Yes

No

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

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Schedule F. Section 509(a)(3) Supporting Organizations (continued)
5

Which of the following describes your relationship with your supported organization(s)?
A majority of your governing board or officers are elected or appointed by your supported organization(s). (Type I supporting
organization)
Your control or management is vested in the same persons who control or manage your supported organization(s). (Type II supporting
organization)
One or more of your officers, directors, or trustees are elected or appointed by the officers, directors, trustees, or membership of your
supported organization(s), or one or more of your officers, directors, trustees, or other important office holders, are also members of
the governing body of your supported organization(s), or your officers, directors, or trustees maintain a close and continuous working
relationship with the officers, directors, or trustees of your supported organization(s). (Type III supporting organization)

6

Describe how your governing board and officers are selected. If you are a Type III organization, also describe how your officers, directors,
or trustees maintain a close and continuous working relationship with the officers, directors, or trustees of your supported organization(s).

7

Do any persons who are disqualified persons (except individuals who are disqualified persons only because they are
foundation managers) with respect to you or persons who have a family or business relationship with any
disqualified persons appoint any of your foundation managers? If "Yes," (1) describe the process by which
disqualified persons appoint any of your foundation managers, (2) provide the names of these disqualified persons
and the foundation managers they appoint, and (3) explain how control is vested over your operations (including
assets and activities) by persons other than disqualified persons.

Yes

No

8

Do any persons who are disqualified persons (except individuals who are disqualified persons only because they are
foundation managers) have any influence regarding your operations, including your assets or activities? If "Yes," (1)
provide the names of these disqualified persons, (2) explain how influence is exerted over your operations (including
assets and activities), and (3) explain how control is vested over your operations (including assets and activities) by
individuals other than disqualified persons.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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Schedule F. Section 509(a)(3) Supporting Organizations (continued)
9

Does your organizing document specify your supported organization(s) by name?
Yes
No
If "Yes," and you selected Type I or Type III above, continue to Line 10.
If "Yes," and you selected Type II, do not complete the rest of Schedule F.
If "No," and you selected Type III above, amend your organizing document to specify your supported organization(s) by name or you will
not meet the organizational test and need to reconsider your requested public charity classification; then continue to Line 10.

9a

Does your organizing document name a similar purpose or charitable class of beneficiaries as to your supported
organization(s)? If "No," amend your organizing document to specify your supported organization(s) by name,
purpose, or class or you will not meet the organizational test and need to reconsider your requested public charity
classification.

Yes

No

Yes

No

If you selected Type II above, do not complete the rest of Schedule F.
10

Do you or will you receive contributions from any person who alone, or combined with family members or an entity at
least 35% controlled by that person, controls any of your supported organizations, or will you receive contributions
from any family member of, or an entity at least 35% controlled by any person who controls any of your supported
organizations? If "Yes," explain.

If you selected Type I above, do not complete the rest of Schedule F.
11

Do the officers, directors, or trustees of your supported organization have a significant voice in your investment
policies, the timing and making of grants, the selection of grant recipients, and in otherwise directing the use of your
income or assets? If "Yes," explain.

Yes

No

12

In each taxable year, do you or will you provide each of your supported organizations with (1) a written notice
addressed to a principal officer of the supported organization describing the type and amount of all of the support
you provided to the supported organization during the immediately preceding taxable year, (2) a copy of your most
recently filed Form 990-series return or notice, and (3) a copy of your governing documents? If "No," explain.

Yes

No

Form 8940 (Rev. 04-2023)

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Schedule F. Section 509(a)(3) Supporting Organizations (continued)
13

Do you exercise a substantial degree of direction over the policies, programs, and activities of your supported
organization(s) and appoint or elect (directly or indirectly) a majority of the officers, directors, or trustees of your
supported organization(s)? If "Yes," explain.

Yes

No

14

Do substantially all of your activities directly further the exempt purposes of one or more supported organizations to
which you are responsive by performing the functions of, or carrying out the purposes of, such supported
organization(s) and but for your involvement would normally be engaged in by such supported organization(s)?
If "Yes," explain and do not complete the rest of Schedule F.

Yes

No

15

Do you distribute at least 85% of your annual net income or 3.5% of the aggregate fair market value of all of your
nonexempt-use assets (whichever is greater) to your supported organization(s)? If "No," explain.

Yes

No

Yes

No

15a How much do you contribute annually to each supported organization?
15b What is the total annual revenue of each supported organization?
15c Do you or the supported organization(s) earmark your funds for support of a particular program or activity? If "Yes,"
explain.

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

EIN:

Page 25

Schedule G. Reclassification of foundation status, including a voluntary request from a public charity for private foundation status
1

Select which foundation classification you are requesting from the list below.
Sections 509(a)(1) and 170(b)(1)(A)(vi) as an organization that receives a substantial part of its financial support in the form of
contributions from publicly supported organizations, from a governmental unit, or from the general public.
Section 509(a)(2) as an organization that normally receives not more than one-third of its financial support from gross investment
income and receives more than one-third of its financial support from contributions, membership fees, and gross receipts from
activities related to its exempt functions (subject to certain exceptions).
Sections 509(a)(1) and 170(b)(1)(A)(i) as a church or a convention or association of churches. (Schedule L)
Sections 509(a)(1) and 170(b)(1)(A)(ii) as a school. (Schedule M)
Sections 509(a)(1) and 170(b)(1)(A)(iii) as a hospital, a cooperative hospital service organization, or a medical research organization
operated in conjunction with a hospital. (Schedule N)
Note: If you are a medical research organization, at the end of this form, upload copies of your governing instruments, bylaws, and
amendments.
Sections 509(a)(1) and 170(b)(1)(A)(iv) as an organization operated for the benefit of a college or university that is owned or operated
by a governmental unit. (Schedule O)
Note: At the end of this form, upload copies of your governing instruments, bylaws, and amendments.
Sections 509(a)(1) and 170(b)(1)(A)(ix) as an agricultural research organization directly engaged in the continuous active conduct of
agricultural research in conjunction with a college or university. (Schedule P)
Section 509(a)(3) as an organization supporting either one or more organizations described in section 509(a)(1) or 509(a)(2) or a
publicly supported section 501(c)(4), (5), or (6) organization. (Schedule F) Check this box if you are a nonexempt charitable trust
described in Section 4947(a)(1) requesting an initial determination that you are described in section 509(a)(3).
Note: At the end of this form, upload copies of your governing instruments, bylaws, and amendments.
Section 509(a)(4) as an organization organized and operated exclusively for testing for public safety.
A private foundation, as described in section 509(a). (Section 1)
A private operating foundation, as described in section 4942(j)(3). (Section 2)
An exempt operating foundation, as described in section 4940(d)(2). (Section 3)

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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EIN:

Schedule G. Reclassification of foundation status, including a voluntary request from a public charity for private foundation status
(continued)
Section 1

Request for reclassification as a private foundation, as described in section 509(a)

1

Do you normally fail to receive more than one-third of your total support from governmental units, direct or indirect
contributions from the public, or a combination of these sources, or you normally fail to receive at least 10 percent
but less one-third of your total support from contributions made directly or indirectly by the general public or from
governmental units? See Regulations section 1.170A-9(f)(3). If "No," explain.

Yes

No

2

Do you normally fail to receive more than one-third of your total support from any combination of gifts, grants,
contributions, membership fees, and gross receipts from permitted sources, and normally receive more than onethird of your support from gross investment income and the excess of the amount of unrelated business taxable
income over the amount of taxes imposed by section 511? If "No," explain.

Yes

No

3

What is your requested effective date of reclassification as a private foundation? (MM/DD/YYYY)

4

Do you meet the governing instrument requirements of section 508(e)? See Revenue Ruling 75-38, 1975-1 C.B.
161.

Yes

No

Section 2
1

Request for reclassification as a private operating foundation, as described in section 4942(j)(3)

List and describe how your qualifying distributions are used directly for the active conduct of your own programs or activities.

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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Schedule G. Reclassification of foundation status, including a voluntary request from a public charity for private foundation status
(continued)
Section 2

Request for reclassification as a private operating foundation, as described in section 4942(j)(3) (continued)

2

Describe any adverse impact if you do not receive the requested status.

3

Are you changing from public charity to private foundation classification? If "No," do not complete the rest of
Schedule G.

Yes

No

3a

Do you normally fail to receive more than one-third of your total support from governmental units, direct or indirect
contributions from the public, or a combination of these sources, or you normally fail to receive at least 10 percent
but less one-third of your total support from contributions made directly or indirectly by the general public or from
governmental units? See Regulations section 1.170A-9(f)(3). If "No," explain.

Yes

No

3b

Do you normally fail to receive more than one-third of your total support from any combination of gifts, grants,
contributions, membership fees, and gross receipts from permitted sources, and normally receive more than onethird of your support from gross investment income and the excess of the amount of unrelated business taxable
income over the amount of taxes imposed by section 511? If "No," explain.

Yes

No

3c

What is your requested effective date of reclassification as a private foundation? (MM/DD/YYYY)

3d

Do you meet the governing instrument requirements of section 508(e)? See Revenue Ruling 75-38, 1975-1 C.B.
161.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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EIN:

Schedule G. Reclassification of foundation status, including a voluntary request from a public charity for private foundation status
(continued)
Section 3

Request for reclassification as an exempt operating foundation, as described in section 4940(d)(2)

1

Are you a private operating foundation as defined in section 4942(j)(3)? If "Yes," explain.

Yes

No

2

Have you been publicly supported under either sections 509(a)(1) and 170(b)(1)(A)(vi) or 509(a)(2) for at least 10
years, or were you an operating foundation, as defined in section 4942(j)(3), as of January 1, 1983? If "Yes," at the
end of this form, upload documentation to support your answer.

Yes

No

3

At all times during the tax year, has your governing body consisted of individuals at least 75% of whom are not
disqualified individuals, as defined in section 4940(d)(3)(B), and been broadly representative of the general public? If
"No," explain.

Yes

No

4

At any time during the year did you have an officer who is a disqualified individual? If "Yes," explain.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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Page 29

Schedule H. Termination of private foundation status under section 507(b)(1)(B)—advance ruling request
1

Select which foundation classification you are seeking from the list below.
Sections 509(a)(1) and 170(b)(1)(A)(vi) as an organization that receives a substantial part of its financial support in the form of
contributions from publicly supported organizations, from a governmental unit, or from the general public.
Section 509(a)(2) as an organization that normally receives not more than one-third of its financial support from gross investment
income and receives more than one-third of its financial support from contributions, membership fees, and gross receipts from
activities related to its exempt functions (subject to certain exceptions).
Sections 509(a)(1) and 170(b)(1)(A)(i) as a church or a convention or association of churches. (Schedule L)
Sections 509(a)(1) and 170(b)(1)(A)(ii) as a school. (Schedule M)
Sections 509(a)(1) and 170(b)(1)(A)(iii) as a hospital, a cooperative hospital service organization, or a medical research organization
operated in conjunction with a hospital. (Schedule N)
Note: If you are a medical research organization, at the end of this form, upload copies of your governing instruments, bylaws, and
amendments.
Sections 509(a)(1) and 170(b)(1)(A)(iv) as an organization operated for the benefit of a college or university that is owned or operated
by a governmental unit. (Schedule O)
Note: At the end of this form, upload copies of your governing instruments, bylaws, and amendments.
Sections 509(a)(1) and 170(b)(1)(A)(ix) as an agricultural research organization directly engaged in the continuous active conduct of
agricultural research in conjunction with a college or university. (Schedule P)
Section 509(a)(3) as an organization supporting either one or more organizations described in section 509(a)(1) or 509(a)(2) or a
publicly supported section 501(c)(4), (5), or (6) organization. (Schedule F)
Note: At the end of this form, upload copies of your governing instruments, bylaws, and amendments.
Section 509(a)(4) as an organization organized and operated exclusively for testing for public safety.

2

Describe how your organizational structure (taking into account any revisions made prior to the beginning of the 60-month period), current
or proposed programs or activities, actual or intended method of operation, and current or projected sources of support are such that you
are likely to satisfy the requirements of your intended public charity classification during the 60-month period.

3

Enter the date of commencement of the 60-month period. (MM/DD/YYYY)
Note: Your notification must be made before the commencement of the 60-month period.

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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Page 30

Schedule I. Notice Only - Termination of private foundation status under section 507(b)(1)(B)
1

Select which foundation classification you are seeking from the list below.
Sections 509(a)(1) and 170(b)(1)(A)(vi) as an organization that receives a substantial part of its financial support in the form of
contributions from publicly supported organizations, from a governmental unit, or from the general public.
Section 509(a)(2) as an organization that normally receives not more than one-third of its financial support from gross investment
income and receives more than one-third of its financial support from contributions, membership fees, and gross receipts from
activities related to its exempt functions (subject to certain exceptions).
Sections 509(a)(1) and 170(b)(1)(A)(i) as a church or a convention or association of churches.
Sections 509(a)(1) and 170(b)(1)(A)(ii) as a school.
Sections 509(a)(1) and 170(b)(1)(A)(iii) as a hospital, a cooperative hospital service organization, or a medical research organization
operated in conjunction with a hospital.
Sections 509(a)(1) and 170(b)(1)(A)(iv) as an organization 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)(ix) as an agricultural research organization directly engaged in the continuous active conduct of
agricultural research in conjunction with a college or university.
Section 509(a)(3) as an organization supporting either one or more organizations described in section 509(a)(1) or 509(a)(2) or a
publicly supported section 501(c)(4), (5), or (6) organization.
Section 509(a)(4) as an organization organized and operated exclusively for testing for public safety.

2

Enter the date of commencement of the 60-month period. (MM/DD/YYYY)
Note: Your notification must be made before the commencement of the 60-month period.

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

EIN:

Page 31

Schedule J. Termination of private foundation status under section 507(b)(1)(B)—60-month period ended
1

Select which foundation classification you are seeking from the list below.
Sections 509(a)(1) and 170(b)(1)(A)(vi) as an organization that receives a substantial part of its financial support in the form of
contributions from publicly supported organizations, from a governmental unit, or from the general public.
Note: At the end of this form, upload a completed Schedule A (Form 990 or 990-EZ), Part II, for the 60-month period.
Section 509(a)(2) as an organization that normally receives not more than one-third of its financial support from gross investment
income and receives more than one-third of its financial support from contributions, membership fees, and gross receipts from
activities related to its exempt functions (subject to certain exceptions).
Note: At the end of this form, upload a completed Schedule A (Form 990 or 990-EZ), Part III, for the 60-month period.
Sections 509(a)(1) and 170(b)(1)(A)(i) as a church or a convention or association of churches. (Schedule L)
Sections 509(a)(1) and 170(b)(1)(A)(ii) as a school. (Schedule M)
Sections 509(a)(1) and 170(b)(1)(A)(iii) as a hospital, a cooperative hospital service organization, or a medical research organization
operated in conjunction with a hospital. (Schedule N)
Note: If you are a medical research organization, at the end of this form, upload copies of your governing instruments, bylaws, and
amendments during the 60-month period.
Sections 509(a)(1) and 170(b)(1)(A)(iv) as an organization operated for the benefit of a college or university that is owned or operated
by a governmental unit. (Schedule O)
Note: At the end of this form, upload a completed Schedule A (Form 990 or 990-EZ), Part II and copies of your governing instruments,
bylaws, and amendments during the 60-month period.
Sections 509(a)(1) and 170(b)(1)(A)(ix) as an agricultural research organization directly engaged in the continuous active conduct of
agricultural research in conjunction with a college or university. (Schedule P)
Section 509(a)(3) as an organization supporting either one or more organizations described in section 509(a)(1) or 509(a)(2) or a
publicly supported section 501(c)(4), (5), or (6) organization. (Schedule F)
Note: At the end of this form, upload copies of your governing instruments, bylaws, and amendments during the 60-month period.
Section 509(a)(4) as an organization organized and operated exclusively for testing for public safety.

2

Describe completely your current operations pertinent to the public charity status, as well as any changes during the 60-month period.

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

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Schedule K. Canadian registered charities: listing on Pub. 78 Data and/or public charity classification
1

Have you received a Notification of Registration from the Canada Revenue Agency? If "Yes," at the end of this form,
upload a copy. If "No," do not complete the rest of Schedule K.

Yes

No

1a

Has your registration been revoked? If "Yes," explain.

Yes

No

2

Have you completed Form 8833, Treaty-Based Return Position Disclosure Under Section 6114 or 7701(b)? If "Yes,"
at the end of this form, upload a copy.

Yes

No

3

Are you requesting recognition of Section 501(c)(3) exemption and listing in Pub. 78 data as an organization eligible
to receive tax-deductible contributions?

Yes

No

4

Enter the date you formed. (MM/DD/YYYY)

5

Select your type of organization.
Corporation
Limited Liability Company (LLC)
Unincorporated Association
Trust

6

Select the foundation classification you are requesting from the list below.
You are a private foundation.
You are described in section 509(a)(1) and 170(b)(1)(A)(vi) as an organization that receives a substantial part of its financial support in
the form of contributions from publicly supported organizations, from a governmental unit, or from the general public.
You are described in section 509(a)(2) as an organization that normally receives not more than one-third of its financial support from
gross investment income and receives more than one-third of its financial support from contributions, membership fees, and gross
receipts from activities related to its exempt functions (subject to certain exceptions).
You are described in sections 509(a)(1) and 170(b)(1)(A)(i) as a church or a convention or association of churches. (Schedule L)
You are described in sections 509(a)(1) and 170(b)(1)(A)(ii) as a school. (Schedule M)
You are described in sections 509(a)(1) and 170(b)(1)(A)(iii) as a hospital, a cooperative hospital service organization, or a medical
research organization operated in conjunction with a hospital. (Schedule N)
You are described in sections 509(a)(1) and 170(b)(1)(A)(iv) as an organization operated for the benefit of a college or university that
is owned or operated by a governmental unit. (Schedule O)
You are described in sections 509(a)(1) and 170(b)(1)(A)(ix) as an agricultural research organization directly engaged in the
continuous active conduct of agricultural research in conjunction with a college or university. (Schedule P)
You are described in section 509(a)(3) as an organization supporting either one or more organizations described in section 509(a)(1)
or 509(a)(2) or a publicly supported section 501(c)(4), (5), or (6) organization. (Schedule F)
You are described in section 509(a)(4) as an organization organized and operated exclusively for testing for public safety.

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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Schedule K. Canadian registered charities: listing on Pub. 78 Data and/or public charity classification (continued)
6a

Are you a private operating foundation?
To be a private operating foundation you must engage directly in the active conduct of charitable, religious,
educational, and similar activities, as opposed to indirectly carrying out these activities by providing grants to
individuals or other organizations.

6b

Yes

No

Describe how you meet the requirements for private operating foundation status, including how you meet the income test and either the
assets test, the endowment test, or the support test. If you have been in existence for less than one year, describe how you are likely to
satisfy the requirements for private operating foundation status.

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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Schedule L. A church, an interchurch organization of local units of a church, a convention or association of churches
1

Do you have a written creed, statement of faith, or summary of beliefs? If "Yes," describe your written creed,
statement of faith, or summary of beliefs.

Yes

No

2

Do you have a literature of your own? If "Yes," describe your literature.

Yes

No

3

Do you have a formal code of doctrine and discipline? If "Yes," describe your code of doctrine and discipline.

Yes

No

4

Describe your religious hierarchy or ecclesiastical government.

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

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Schedule L. A church, an interchurch organization of local units of a church, a convention or association of churches (continued)
5

Are you part of a group of churches with similar beliefs and structures? If "Yes," explain.

Yes

No

6

Do you have a form of worship? If "Yes," describe your form of worship.

Yes

No

7

Do you have regularly scheduled religious services? If "Yes," describe the nature of the services.

Yes

No

7a

What is the average attendance at your regularly scheduled religious services?

8

Do you have an established place of worship? If "Yes," describe your established place of worship or where you
meet to hold regularly scheduled religious services.

Yes

No

9

Do you have an established congregation or other regular membership group? If "No," continue to Line 10.

Yes

No

9a

How many members do you have?

Form 8940 (Rev. 04-2023)

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Schedule L. A church, an interchurch organization of local units of a church, a convention or association of churches (continued)
9b

Do you have a process by which an individual becomes a member? If "Yes," describe the process.

Yes

No

9c

Do your members have voting rights, rights to participate in religious functions, or other rights? If "Yes," describe the
rights your members have.

Yes

No

9d

May your members be associated with another denomination or church?

Yes

No

9e

Are all of your members part of the same family?

Yes

No

10

Do you conduct baptisms, weddings, funerals, or other religious rites?

Yes

No

11

Do you have a school for the religious instruction of the young?

Yes

No

12

Do you have ministers or religious leaders? If "Yes," describe these roles and explain whether the ministers or
religious leaders are ordained, commissioned, or licensed after a prescribed course of study.

Yes

No

13

Do you have schools for the preparation of your ordained ministers or religious leaders?

Yes

No

14

Do you ordain, commission, or license ministers or religious leaders? If "Yes," describe the requirements for
ordination, commission, or licensure.

Yes

No

Form 8940 (Rev. 04-2023)

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Name:

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EIN:

Schedule L. A church, an interchurch organization of local units of a church, a convention or association of churches (continued)
15

Do you have other information you believe should be considered regarding your status as a church? If "Yes," explain.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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EIN:

Schedule M. Schools, Colleges, and Universities
1

Do you normally have a regularly scheduled curriculum, a regular faculty of qualified teachers, a regularly enrolled
student body, and facilities where your educational activities are regularly carried on?

Yes

No

2

Is the primary function of your school the presentation of formal instruction? If "No," continue to Line 3.

Yes

No

2a

Select the best description(s) of your school.
Elementary school
Secondary school
Charter school
College or university
Technical school
Other school (describe)

3

Are you a public school because you are operated by a state or subdivision of a state or operated wholly or
predominantly from government funds or property? If "Yes," explain how you are operated by a state or subdivision
of a state. Do not complete the rest of Schedule M.

Yes

No

4

Were you formed or substantially expanded at the time of public school desegregation in the school district or county
in which you are located?

Yes

No

5

Has a state or federal administrative agency or judicial body ever determined that you are racially discriminatory? If
"Yes," explain.

Yes

No

6

Has your right to receive financial aid or assistance from a governmental agency ever been revoked or suspended?
If "Yes," explain.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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Schedule M. Schools, Colleges, and Universities (continued)
7

Have you adopted a racially nondiscriminatory policy as to students in your organizing document, bylaws, or by
resolution of your governing body? If "Yes," state where the policy is located or if adopted by resolution of your
governing body.

Yes

No

8

Do your brochures, application forms, advertisements, and catalogues dealing with student admissions, programs,
and scholarships contain a statement of your racially nondiscriminatory policy? If "Yes," continue to Line 9.

Yes

No

8a
9

9a

By checking this box, you agree that all future printed materials, including website content, will contain the required nondiscriminatory
policy statement.
Have you made your racially nondiscriminatory policy known to all segments of the general community you serve by:
a) publishing a notice of your policy in a newspaper of general circulation that serves all racial segments of the
community; b) publicizing your policy over broadcast media in a way that is reasonably expected to be effective; or
c) displaying a notice of your policy at all times on your primary, publicly accessible internet home page in a manner
reasonably expected to be noticed by visitors to the homepage? If "Yes," continue to Line 10.

Yes

No

By checking this box, you agree that you will publicize your nondiscriminatory policy in a way that meets the requirements of Revenue
Procedure 75-50, 1975-2 C.B. 587, as modified by Revenue Procedure 2019-22, I.R.B. 1260.

10

Do or will you (or any of your departments or divisions) discriminate in any way on the basis of race with respect to
admissions, use of facilities or exercise of student privileges, faculty or administrative staff, or scholarship or loan
programs? If "Yes," for any of the above, explain fully.

11

Complete the table below to show the racial composition for the current academic year and projected for the next academic year. If you are
not operational, submit an estimate based on the best information available (such as the racial composition of the community you serve).

Yes

No

For each racial category, enter the number of (a) students, (b) faculty, and (c) administrative staff. Provide actual numbers rather than
percentages for each racial category.
Racial Category

(a) Student Body
Current Year

Total

0

Next Year

0

(b) Faculty
Current Year

0

Next Year

0

(c) Administrative Staff
Current Year

0

Next Year

0

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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EIN:

Schedule M. Schools, Colleges, and Universities (continued)
12

In the table below, enter the number and amount of loans and scholarships awarded to enrolled students by racial categories. Provide
actual numbers rather than percentages for each racial category.
Check here if you will not provide any loans or scholarships to students.

Racial Category

Number of Loans
Current Year

Total

0

Next Year

0

Amount of Loans
Current Year

$0.

Next Year

$0.

Number of Scholarships
Current Year

0

Next Year

0

Amount of Scholarships
Current Year

$0.

Next Year

$0.

13

List your incorporators, founders, board members, and donors of land or buildings, whether individuals or organizations.

14

Do any of your incorporators, founders, board members, and donors of land or buildings, whether individuals or
organizations, have an objective to maintain segregated public or private school education? If "Yes," explain.

Yes

No

15

Will you maintain records according to the nondiscrimination provisions contained in Revenue Procedure 75-50?
If "No," explain.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

Page 41

EIN:

Schedule N. Hospitals and Medical Research Organizations
1

Are you a medical research organization (an organization whose principal purpose or function is medical research,
and which is directly engaged in the continuous active conduct of medical research) operated in conjunction with a
hospital? If "No," continue to Line 2.

1a

Name the hospitals with which you have a relationship and describe the relationship.

1b

List your assets showing their fair market value and the portion of your assets directly devoted to medical research. Do not complete the
rest of Schedule N.

2

Are you applying for exemption as a cooperative hospital service organization described in section 501(e)? If "Yes,"
explain. Do not complete the rest of Schedule N.

Yes

No

3

Are all the doctors in the community eligible for staff privileges? If "No," give the reasons why and explain how the
medical staff is selected.

Yes

No

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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Schedule N. Hospitals and Medical Research Organizations (continued)
4

Do or will you provide medical services to all individuals in your community who can pay for themselves or are able
to pay through some form of insurance? If "No," explain.

Yes

No

5

Do you or will you maintain a full-time emergency room? If "Yes," continue to Line 6.

Yes

No

5a

Are you a specialty hospital or would emergency services be duplicative based on your region or locality?

Yes

No

6

Do you provide free or below cost services? If "Yes," describe your policy for determining when and to whom you
provide these services and how these services promote the organization's benefit to the community.

Yes

No

7

Do you or will you carry on a formal program of medical training or medical research? If "Yes," describe such
programs, including the type of programs offered, the scope of such programs, and affiliations with other hospitals or
medical care providers with which you carry on the medical training or research programs.

Yes

No

8

Do you or will you carry on a formal program of community education? If "Yes," describe such programs, including
the type of programs offered, the scope of such programs, and affiliation with other hospitals or medical care
providers with which you offer community education programs.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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EIN:

Schedule N. Hospitals and Medical Research Organizations (continued)
9

Is your board of directors composed of a majority of individuals who are representative of the community you serve,
or do you operate under a parent organization whose board of directors is composed of a majority of individuals who
are representative of the community you serve? If "Yes," continue to Line 10.

9a

List each board member's name and business, financial, or professional relationship with the hospital. Also, identify each board member
who is representative of the community and describe how that individual is a community representative. If you operate under a parent
organization whose board of directors is not composed of a majority of individuals who are representative of the community you serve,
provide the requested information for your parent's board of directors as well.

10

Do you operate a facility which is required by a state to be licensed, registered, or similarly recognized as a hospital?
If "No," do not complete the rest of Schedule N.

Yes

No

Yes

No

10a Do you conduct a community health needs assessment (CHNA) at least once every three years and adopt an
implementation strategy to meet the community health needs identified in the assessment as required by section
501(r)(3)? If "No," explain.

Yes

No

10b Do you have a written financial assistance policy (FAP) and a written policy relating to emergency medical care as
required by section 501(r)(4)? If "No," explain.

Yes

No

10c Do you both (1) limit amounts charged for emergency or other medically necessary care provided to individuals
eligible for assistance under your FAP to not more than amounts generally billed to individuals who have insurance
covering such care, and (2) prohibit use of gross charges as required by section 501(r)(5)? If "No," explain.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

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Schedule N. Hospitals and Medical Research Organizations (continued)
10d Do you make reasonable efforts to determine whether an individual is FAP-eligible before engaging in extraordinary
collection actions as required by section 501(r)(6)? If "No," explain.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

Page 45

EIN:

Schedule O. An organization operated for the benefit of a college or university owned or operated by a governmental unit, as
described in sections 509(a)(1) and 170(b)(1)(A)(iv)
1

Do you normally receive a substantial part of your support (excluding income you receive from an activity
substantially related to the charitable, educational, or other section 501(c)(3) purpose that is the basis for your
exemption under section 501(a)) from the United States or any State or its political subdivision or from direct or
indirect contributions from the general public? If "No," explain.

Yes

No

2

Do your bylaws or other organizational documents indicate that you are organized and operated exclusively to
receive, hold, invest, and administer property and to make expenditures to or for the benefit of a college or university
described in sections 509(a)(1) and 170(b)(1)(A)(ii)?

Yes

No

3

Is the college or university an agency or instrumentality of a state or political subdivision thereof, or is it owned or
operated by a state or political subdivision thereof, or by an agency or instrumentality of one or more States or
political subdivisions? If "Yes," list the name and EIN of the college or university.

Yes

No

Form 8940 (Rev. 04-2023)

Form 8940 (Rev. 04-2023)

Name:

EIN:

Page 46

Schedule P. An agricultural research organization described in sections 509(a)(1) and 170(b)(1)(A)(ix)
1

Explain in detail how you are operated in conjunction with a land grant college or university or a non-land grant college of agriculture (as
defined in section 1404 of the Agricultural Research, Extension, and Teaching Policy Act of 1977).

2

Explain in detail your agricultural research program and how contributions to such program will be spent.

Form 8940 (Rev. 04-2023)