Form AR1023CT Application for Income Tax Exempt Status

(race religion sex national origin etc ) 432 Lessen neighborhood tensions 449 Other civil rights activities (see 031 and 160) 10 IRC Exempt Under 12 IRS Expiration Date 2 FEIN 3 Name and telephone number of person to be contacted if additional information is needed ( ) 4 Tax Year (Month/Year) 6 Activity Codes (See Instructions) 7 List subsection of ACA 26 51 303(a) applying under 9 Domestic or Foreign Achievement prizes or awards (use 914) Attracting new industry (use 403) Boys Club Little League etc (Use 321) Cooperative hospital service organization (use 157) Day care center (use 574) Farmers cooperative marketing or purchasing (use 234) Financial support of cultural organizations (Use 602) Financial support of schools colleges etc (use 602) gamblers etc Garden club (use 356) Gifts or grants to individuals (use 561 ) Insurance or other benefit for members (See Employee or Membership Benefit Org ) Nursing or convalescent home (use 152) Orphanage (use 326) Publishing activities (use 120) Scholarships (other) (use 040) Scholarships for children of employees (Use 039) School or college athletic association (use 038) Scientific research (see Scientific Research Activities) Section 501(c)(20) Student bookstores (use 918) Student housing (use 042) Student loans (use 041) Student travel (use 299) Testing products for public safety (use 905) Training of or aid to the handicapped Travel tours (use 299) (1) Fraternal benefit societies orders organized for profit but operated exclu produce furnished by them; or associations: sively for the promotion of social (2) Domestic life and disability which inures to the benefit of any (2) of this section mutual ditch or (3) Cemetery corporations; otherwise attempting to influence (4) Business leagues chambers of participate in or intervene in including (5) Civic leagues or organizations not (6) Farmers' or other mutual hail (7) Farmers' fruit growers' or like (8) Labor agricultural or horticultural welfare; (A) Operating under the lodge organizations no part of the net system or for the exclusive benefit of earnings of which inures to the benefit (B) Providing for the payment of organized and operated exclusively for 001 Church synagogue etc 002 Association or convention of churches 003 Religious order 004 Church auxiliary 005 Mission 006 Missionary activities 007 Evangelism 008 Religious Publishing activities Bookstore (use 918) Genealogical activities (use 094) 029 Other religious activities 030 School college trade school etc 031 Special school for the blind handicapped etc 032 Nursery school 034 Alumni association or group 035 Parent or parent teacher association 036 Fraternity or sorority Key club (use 323) 037 Other student society or group 038 School or college athletic association 039 Scholarships for children of employees 040 Scholarships (other) 041 Student loans 042 Student housing activities 043 Other student aid 044 Student exchange with foreign country 045 Student operated business 046 Private School 059 Other school related activities 060 Museum zoo planetarium etc 061 Library 062 Historical site records or reenactment 063 Monument 064 Commemorative event (Centennial festival pageant etc ) 065 Fair 088 Community theatrical group 089 Singing society or group 090 Cultural performances 091 Art exhibit 092 Literary activities 093 Cultural exchanges foreign country 094 Genealogical activities 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 your organizational document Describe each activity separately in the order of importance Each description should include as a minimum the following: (a) a detailed description of the activity including its purpose; (b) when the activity was or will be initiated; and (c) where and by whom the activity will be conducted 11 IRS Approval Date 119 Other cultural or historical activities 120 Publishing activities 121 Radio or television broadcasting 122 Producing films 123 Discussion groups forums panels lectures etc 124 Study and research (nonscientific) 125 Giving information or opinion (See Advocacy) 126 Apprentice training 13 Has the organization filed Arkansas Corporation Income Tax Returns? 0 Yes 0 No (If Yes state the tax years filed) 14 Check the box for your type of organization BE SURE TO ATTACH A COMPLETE COPY OF THE CORRESPONDING DOCUMENTS TO THE APPLICATION BEFORE MAILING 01 0 Corporation: Attach a copy of your Articles of Incorporation (including amendments and restatements) showing approval by the appropriate State official; also include a copy of your Bylaws 02 0 Trust: Attach of copy of your Trust Indenture or Agreement including all appropriate signatures and dates 03 0 Cooperative: Attach a copy of your creating documents and a copy of your Bylaws Rules and Regulations 04 0 Partnership: Attach a copy of your Partnership Agreement and Bylaws if any 05 0 Association: Attach a copy of your Articles of Association Constitution or other creating documents with a declaration or other evidence the organization was formed by adoption of the document by more than one person; also include a copy of your Bylaws If you are a corporation or an unincorporated association that has not yet adopted Bylaws check here 0 000000000000 149 Other instruction and training 150 Hospital 151 Hospital auxiliary 152 Nursing or convalescent home 153 Care and housing for the aged (see also 382) 154 Health clinic 155 Rural medical facility 156 Blood bank 157 Cooperative hospital service organization 158 Rescue and emergency service 159 Nurses register or bureau 160 Aid to the handicapped (see also 031) 161 Scientific research (diseases) 162 Other medical research 163 Health insurance (medical dental optical etc ) 164 Prepared group health plan 165 Community health planning 166 Mental health care 167 Group medical practice association 168 In faculty group practice association 169 Hospital pharmacy parking facility food services etc 179 Other health services 180 Contract or sponsored scientific research for industry 181 Scientific research for government Scientific research (diseases)(use 161) 199 Other scientific research activities 1a Full Name of Organization (As shown in organizing document) 1b C/O Name (If applicable) 1c Address (Number Street and Room or Suite Number) 1d City or Town State and ZIP Code 2 Will any of the organization s income be credited to surplus or inure to the benefit of any private stockholder or individual? Yes No (If yes explain below ) 200 Business promotion (chamber of commerce business league etc ) 201 Real estate association 202 Board of trade 203 Regulating business 204 Promotion of fair business practices 205 Professional association 206 Professional association auxiliary 207 Industry trade shows 208 Convention displays 209 Research development and testing 210 Professional athletic league 211 Underwriting municipal insurance 212 Assigned Risk Insurance Activities 213 Tourist Bureau 229 Other business or professional group 230 Farming 231 Farm bureau 232 Agricultural group 233 Horticultural group 234 Farmers cooperative marketing or purchasing 235 Financing crop operations FFA FHA 4 H Club etc (Use 322) Fair (Use 065) 236 Dairy herd improvement association 237 Breeders association 249 Other farming and related activities 250 Mutual ditch irrigation telephone electric company or like organization 251 Credit union 252 Reserve funds or insurance for domestic building and loan association cooperative bank or mutual savings bank 253 Mutual insurance company 254 Corporation organized under an Act of Congress (see also 904) 259 Other mutual organization 260 Fraternal beneficiary society order or association 261 Improvement of conditions of workers 262 Association of municipal employees 263 Association of employees 264 Employee or member welfare association 265 Sick accident death or similar benefits 266 Strike benefits 267 Swimming or tennis club 267 Unemployment benefits 268 Pension or retirement benefits 269 Vacation Benefits 279 Other services or benefits to members or employees 280 Country club 281 Hobby club 282 Dinner club 283 Variety club 284 Dog club 285 Women s club 286 Hunting or fishing club 288 Other sports club 296 Community center 297 Community recreational facilities (park play ground etc ) 298 Training in sports 299 Travel Tours 3 What are or will be the organization s sources of financial support? List in order of size 300 Amateur athletic association 301 Fundraising athletic or sport events 317 Other sports or athletic activities 318 Other recreational activities 319 Other social activities 320 Boy Scouts Girl Scouts etc 321 Boys Club Little League etc 322 FFA FHA 4 H Club etc 323 Key Club 324 YMCA YWCA YMHA etc 325 Camp 326 Care and housing of children (orphanage etc ) 327 Prevention of cruelty to children 328 Combat juvenile delinquency 333 Faculty group 349 Other youth organization or activities 350 Preservation of natural resources (conservation) 351 Combating or preventing pollution (air water etc ) 352 Land acquisition for preservation 353 Soil or water conservation 354 Prevention of scenic beauty Litigation (see Litigation and Legal Aid Activities) Combat community deterioration (use 402) 355 Wildlife sanctuary or refuge 356 Garden club 379 Other conservation environmental or beautification 380 Low income housing 381 Low and moderate income housing 382 Housing for the aged (see also 153) 398 Instruction and guidance on housing 399 Other housing activities 4 Describe the organization s fundraising program both actual and planned and explain to what extent it has been put into effect Include details of fundraising activities such as selective mailings formation of fundraising committees use of volunteers or professional fundraisers etc Attach representative copies of solicitations for financial support 400 Area development redevelopment or renewal Housing (see Housing Activities) 401 Homeowners association 402 Other activity aimed at combating community 430 Defense of human and civil rights 431 Elimination of prejudice and discrimination 460 Public interest litigation activities 461 Other litigation or support of litigation 462 Legal aid to indigents 463 Providing bail 465 Plan under IRC motion 120 480 Propose oppose or support legislation 481 Voter information on issues or candidates 482 Voter education (mechanics of registering 5 Attach a copy of the latest financial statement showing the assets liabilities receipts and disbursements of the organization 5 Date Incorporated or Formed 515 Taxes or tax exemption 516 Separation of church and state 517 Government aid to parochial schools 518 U S foreign policy 519 U S military involvement 520 Pacifism and peace 521 Economic political system of U S 522 Anti communism 523 Right to work 524 Zoning or rezoning 525 Location of highway or transportation system 526 Right of criminal defendants 527 Capital punishment 528 Stricter law enforcement 529 Ecology or conservation 530 Protection of consumer interest 531 Medical care service 532 Welfare system 533 Urban renewal 534 Busing students to achieve racial balance 535 Racial integration 538 Use of intoxicating beverages 537 Use of drugs or narcotics 538 Use of tobacco 539 Prohibition of erotica 540 Sex education in public schools 541 Population control 542 Birth control methods 543 Legalized abortion 559 Other matters 561 Gifts or grants to individuals (other than scholarships) 562 Other loans to individuals 563 Marriage counseling 564 Family planning 565 Credit counseling and assistance 566 Job training counseling or assistance 567 Draft Counseling 568 Vocational counseling 569 Referral service (social agencies) 572 Rehabilitating convicts or ex convict 573 Rehabilitating alcoholics drug abusers compulsive 574 Day care center 575 Services for the aged (see also 153 and 382) 580 Supplying money goods or services to the poor 600 Community Chest United Way etc 601 Booster club 602 Gifts grants or loans to other organizations 603 Nonfinancial Services or facilities to other organization 8 Date began activity in Arkansas 900 Cemetery or burial activities 901 Perpetual care fund (cemetery columbarium etc ) 902 Emergency or disaster aid fund 903 Community trust or component 904 Government instrumentality or agency (see also 254) 905 Testing products for public safety 906 Consumer interest group 907 Veterans activities 908 Patriotic activities 909 4947(a)(1) Trust 910 Domestic organization with activities outside US 911 Foreign organization 912 Title holding corporation 913 Prevention of cruelty to animals 914 Achievement prizes or awards 915 Erection or maintenance of public building or works 916 Cafeteria restaurant snack bar food services etc 917 Thrift shop retail outlet etc 918 Book gift or supply store 919 Advertising 920 Association of employees 921 Loans or credit reporting 922 Endowment fund or financial services 923 Indians (tribes cultures etc ) 924 Traffic or tariff bureau 925 Section 501(c)(1) with 50% deductibility 926 Government instrumentality other than 927 Fundraising 928 4947(a)(2) trust 930 Prepaid legal service plan exempt under IRC 931 Withdrawal liability payment fund 990 Section 501 (k) child care organization activities activities 509 Other legislative and political activities Activities Directed to Other Organizations Advocacy and (9) Corporations trusts and any animals no part of the net earnings of Application for Exempt Status Application for Income Tax Exempt Status AR1023CT STATE OF ARKANSAS area 404 Community promotion Community recreational facility (Use 297) Community Center (use 296) 405 Loans or grants for minority businesses Job training counseling or assistance (Use 566) Day care center (Use 574) Referral service (social agencies) (use 569) Legal aid to indigents (Use 462) 406 Crime prevention 407 Voluntary firemen s organization or auxiliary Rescue squad (Use 158) 408 Community service organization 429 Other inner city or community benefits activities as sales agent for the purpose of assessments dues and fees collected association or their dependents; prevention of cruelty to children or Attempt to influence public opinion concerning: 510 Firearms control 511 Selective Service System 512 National defense policy 513 Weapons systems 514 Government spending benefit of any private stockholders or candidate for public office Business and Professional Organization character but only if eighty five Civil Rights Activities Code Religious Activities Code Scientific Research Activities commerce or boards of trade not the publishing or distributing of community chest fund or foundation Conservation Environmental and Beautification Activities cooperative telephone companies or CORPORATION INCOME TAX SECTION Cultural Historical or Other Educational Activities cyclone or fire insurance companies deterioration 403 Attracting new industry or retaining Industry in an Employee or Membership Benefit Organization Farming and Related Activities Follow instructions as stated in Part II Lines 1 through 5 from members for the sole purpose of Health Services and Related Activities Housing Activities I declare under the penalties of perjury that I am authorized to sign this application on behalf of the 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 Title or Authority of Signer Date ies operations or type of organization and enter on individuals; Inner City or Community Activities Instructions for Form AR1023CT insurance companies and foreign private shareholder or individual no insurance companies; substantial part of the activities of irrigation companies mutual or Legislative and Political Activities life sick accident or other benefits to religious charitable scientific literary like organizations of a purely local Line 10 Enter the section and subsection of the Internal Revenue Code under which this organization is exempt Example: 501 (c)(3) Line 11 Enter the month day and year that approval for exempt status was received from the Internal Revenue Service Line 12 Enter the month day and year of the expiration date on the Ruling letter from the Internal Revenue Service if the organization's exempt status was granted to a specific date Line 13 Enter the ending month and year of each tax year for which an Arkansas Corporation Income Tax return has been filed Line 14 Check the appropriate box for your type of organization and attach a complete copy of the requested documents Line 1a Enter full name of organization as shown in the creating document including amendments Line 1b Enter the name of the individual to receive organization's correspondence Line 1c Enter full address (number street room or suite number) Line 1d Enter city state and zip code Line 2 Enter the Federal Employer Identification Number (FEIN) If the organization is not required to have a FEIN enter "N/A" and we will assign an Arkansas identification number to be used on the AR1023CT However the assigned Arkansas identification number cannot be used on any federal state or other documents that require a FEIN Line 3 Enter name and telephone number of the person to contact during business hours if more information is needed This should be an officer director or a person with power of attorney who is familiar with the organization's activities and is authorized to act on its behalf Line 4 Enter the ending month and year of the organization's annual accounting period Line 5 Enter the month day and year the organization became a legal entity For a corporation this is the date that the Articles of Incorporation were approved by the appropriate state official For an unincorporated organization it is the date its constitution or Articles of Association were adopted For a partnership it is the date of the Partnership Agreement Line 6 Select up to three of the Federal code numbers listed on reverse side of this page that best describes or most accurately identifies the organization's purpose activities or type of organization Enter the codes in order of importance Line 7 Enter subsection of ACA 26 51 303(a) applying under (subsection listed below) Line 8 Enter the month day and year of first activity in Arkansas Line 9 Enter "D" (domestic) if incorporated or organized in Arkansas or enter "F" (foreign) if incorporated or organized in another state Litigation and Legal Aid Activities marketing the products of members and meeting losses and expenses; legislation and which does not Mutual Organizations net earnings of which inures to the behalf of or in opposition to any Note: If the above spaces are insufficient for response you may attach additional pages as necessary of the organization consists solely of operating under the lodge system; or other domestic insurance companies organizations organized and operated organized for profit and no part of the statements any political campaign on Other Activities Directed to Individuals Other Instruction and Training Activities Other Purposes and Activities Part I PART I Identification of Applicant Part II percent (85%) or more of the income Revised 9/97 sales less the necessary sellingexpenses on the basis of the quantity of Schools Colleges and Related Activities Section 501(c) Sports Athletic Recreational and Social Activities the members of a fraternity itself of any private stockholder or member; the members of such society order or or educational purposes or for the those specified in subdivisions (1) and turning back to them the proceeds of voting etc ) 483 Support oppose or rate political candidates 484 Provide facilities or services for political campaign which is carrying on propaganda or writing lines of insurance other than Youth Activities