Form 1023 Checklist (Revised December 2017) Application for Recognition of Exemption under Section 501(c)(3) of the Internal Revenue Cade Note: Retain a copy of the completed Form 1023 in your permanent records. Refer to the Generel Instructions regarding Public Inspection of approved applications. Check each boxe finish your application (Form 1029). Sond this comploted Checklist with your file application. Ifyou have not answorad all the Trems below, your application may be returned to you as incompre Assemble the application and materials in this order. + Form 1023 Checkisst + Form 2648, Power of Attorney and Declaration of Representative (it fling) + Form 8821, Tax information Authorization (i filing) + Expeaite request (Frequesting) + Application (Form 1028 and Schedules A through H, as required) * Articles of organization + Amendments to articles of organization in chronological order + Byiaws or other rules of operation and amendments + Documentation of nondiscriminatory policy Tor schools, as requited By Schedule & * Form 5758, Electior/Revocation of Election by an Eligible Section 801(eK.3) Organization To Make Expenditures To Influence Legislation of fling) + Allother attachments, including explanations, financial data, and printed materials or publications. Label each page with name and ENN. User fee payment placed in envelope on top of checklist. DO NOT STAPLE or otherwise attach your ‘check or money arder to your application, Instead, just place itn the envelope. [21 Employer identification Nurnber (EIN) [2 Completed Parts | through XI of the application, including any requested infrmation and any required Schedules A through H. * You must provide specific details about your past, present, and planned activities. * Generalizations or failure to answer questions in the Form 1023 application will prevent us from recognizing you as tax exempt. * Describe your purposes and proposed activities in specific easily understood terms. ++ Financial information should correspond with proposed activities, [1 Schedules. Submit only those schedules that apply to you and check either “Yes” or *No” below. Schedule Yes __ Nod ScheduleE Yes Nov ScheduleB Yes __ No # ScheduloF Yos Nov Schedule Yes _ Nov ScheduleG Yes __ Nov ScheduleD Yes Now Schedule Yes _ NovIZ Anexact copy of your complete articles of organization (creating document), Absence of the proper purpose and dissolution clauses is the number one reason for delays in the issuance of determination letters * Location of Purpose Clause from Part Il line 1 (Page, Article and Paragraph Number) aril * Location of Dissolution Glause from Part Il line 2b oF 2c (Page, Article and Paragraph Number} or by operation of state faw Articte Vil pages 2.8 Signature of an olficer, director, trustee, oF other offical who is authorized to sign the application. Signature at Part XI of Form 1023. [2 Your name on the application must be the same as your legal name as it appears in your articles of ‘organization, Send completed Form 1028, user fee payment, and all other required information, to: Internal Revenue Service ‘Attention: EO Determination Letters Stop 31 P.O. Box 12192 Covington, KY 41012-0192 It you are using express mail ora delivery service, send Form 1023, user fee payment, and attachments to: intemal Revenue Service Attention: EO Determination Letters Stop 31 201 West Rivercenter Boulevard Covington, KY 41011‘om 2848 Serta and Declaration iaonahowus Sones > tntormaton st Fon 2648s Power of Atiomey Caution: A soparae Form 2848 must be completed foreach taxpayer: Form 2848 wi a be Honored for any purpose otha har ropresontation bafoa the IRS, Taxpayer name an aderess ‘Then District Gosporation S Worth Laut Strat Remand, Virginia 23220 Power of Attorney Taxpayer information Taxpayer must sin and dato ths frm en page, eT of Representative insirctons i wo gontonz0%@ “Taxpayar Ganiionion rarer) pease Daytime Tophone nana | Plan ruber apaeaoy ae Dallas, Texas 75202 Fexto aa-ya0-7103 z Nc eaamemianie @ | anintiec wee Nate {heck to be sent copies of waies and commissions EZ amo and aero Telephone No. Foxe. (Noto: soni notices and communications loony wn mposinstves) | Check nove Address] we eet ato COAE No, E za Noe: HS sans noc and canna Yo aly wo reeset) ‘iphone No" [J “Tati. {oteprestet he taxpayer before the heal Reve Sorview and pororm the following acta: a ‘ets autorized fy ae requ to complete this Be 3, Wt wx he es esrb iS, aire iy roots) trae ad Injen cane ax oat dopa | can pro ith espe oe lara desaled bo, Far exam, ener stall ae the ary ton yeoman, const osm orunenis se ttn ne far aang x ops skp arta ‘esziglonal Mate rome, plana Payal Easy Eee, GR Welder, Prete epg, PU, FC, a Panay, So. SDA Shred epost Tax Foon Murbor (1040, 97,720, et) apoteabia) ‘Years or Perot i potenti (Goo ncvuctors) Payor Soe 8H Stes argon Payment eso nso Foren 1028 In conction with exemption application “4 Specie use not recorded on Contallod Authorization Fil (CA). the pout oF alionay for Scio ue not rca on CAR, ______eteck tis box Se tho nsrutions for Line 4. Specific Use Not Record on CAF . ro ‘58 Additional acts authorized, n addion tothe ace lsiod on i above, ahr my represents operon the allowing as (00 Instetions tor ine for mor lrraton lAuthoree eisctosur to tia pares; 1 Substiue adel mprecentatiots, C1Sign a ums Flower acts aunoredt Fon BAB er POT) For Privacy Roland Paporvork Reduolion Act Notice, baa the matruations anFoam 2048 ie. 12.2018) aan 2 1b Specific acts not authorized, Ni represent) ls re) not aulhorzed io endere or tiewise nagotalo any chook puaudng racing ar ooapting payment by ary maana, lace orate, no an account owed or Coron by th rapes avs) oe yf Ot ‘nity wit whom the represeotatives fre) essecated) insu by to government a oapoct of fedora tax Habit. lst ay other specie deans to the act aor authorized inthe power of ttomoy oo nseuctions fr to Sb {6 Retention/ravocation of prior power) of attomoy. The fing of tis power of atomgy automaticaly royokos al var powers) of srry wih ental eens Sacer esa atin a uc ands ovr Ws ocr yO ot wat {fe ravoke apr power of alomoy, ook ro YOU MUST ATTACH A COPY OF ANY POWER OF ATTORNEY YOU WANT TO RENIAIN IN EFFECT. 7 Signoture of taxpayer. 1a tax mator concer 8 yaar in which a ela vei was Med each spousa must ea saparate power alton ava iF thay are apeniing the sae ropeesentalval) signed by a cerparate ole, parr, sure, x mare srt, exter, roca Acmintator, or tuszon on Baha Oe akoAyo, eat at avo ts fgal auton to executes form on Gohl fbi taxpayer IE NOT tite ‘AND DATED, THE IRS WILL RETURN THIS POWER OF ATTORNEY TO THE TAXPAYER. bes /-/) K rroitn alshs 1s (rappoab) corti we WH Distrie Corporation Pram of taiaayr Fm | hr ha nd Declaration of Representative Under pennies of pray, by my Sigature heow | dock ha * Lar pot eure susoendod or shared from practice, of nab for practic, before the nema leven Sees + Lam subject to rouliions contained in rear 250 (81 GFR, Subbie A, Pat 1, a8 mended, goveming sete tore the bol Fewer Sac: ‘Lam anhonea 10 represent tho taxpayer ideod in Pat fr to matt) spueied tore; nd * Lacy ane ofthe tolaning: 4 Attornay-— niombsrin good stancing o the aro he hight court of tha jtiano bow Coed Pube Ascountant— teense 10 practivo as a cert pubic accountants activo nth juin shown bob nat Ajort— erro! as an agent by the ined Revere Service pa he rquremants of Circa 200. COffoar—a hon xe oicer of the taxpayer organization, FrulTme Empoyea-a ful ie employe ofthe taxpayer Family Mantar—2 manor o th toxpayar's metal ai spouse, pan, ch grandparet rack stap-parek, steht, boi, os) vole Actuny enrolled aan actu bythe Joint Baa forthe Enea af Aetuaias under 20 U.S.C, 1242 Ohe ato to atioe bara ‘nt Revenue Sori ie bntod ty ston 10.3 of Cl 230), none Retur Proparer— Authority to practice bofore the RS site. An reroll eth prepare may Fepresent. proved ths prepare (1) prepare an ed eu 07 cae for ed oF peeved ther so sigs space on he on: 2] wan eb sign tha eo ‘hl for refuse) has a vald PIN, and (1 oscars th requir fevun Fling Soason Pragrary Racor o! Corgis) See Specta Puls ‘and Requirements or Unenroiled Return Praparers the instructions Tor saduonal information. ic Sunt ttomoy 0 PA—reoives purmisaton to rapason taxpayers oles the IRS by vite of her statue asa law, busines, or avcouning ‘slasent working an LTC or SIGH Soe stein for Pat or akin craaion i age 1 Emolea Retement Plan Agont—erroted as areteemant plan agent undor the raquromants of Cul 230 (the utr to practice etre th Intra Rear Service fed by srtion 10). > IF THIS DECLARATION OF REPRESENTATIVE IS NOT COMPLETED, SIGNED, AND DATED, THE IRS WILL RETURN THE POWER OF ATTORNEY, REPRESENTATIVES MUST SIGN IN THE ORDER LISTED IN PART I, LINE 2 Note For desraione enor your ite, poston, o¢ atone tha taxpayer nthe “Lens eso olan ewnsing araciton] Ba, heanse, catiicaton, Designation [eit of iter | gitar or oro sa conaing athonty | —"rurnbor apples) (Gappienbe) pe eae owe | Margond B- Apert | !alu] 1 uw | Abageark~ ft Pert ,_|inlulve Fam 2848 on (aOR)ron 1023 > Application for Recognition of Exemption ‘on No. 1516: in ction 504(c)(3) of the Internal Revenue Code | Wotstoaroreanse Bo-omeree017 | Do not mtr soca ecnty mmr thief any be mac pu, | oa See > cot wos gowFormfoa fortune and tho test fomaten Feros Use the instructions to comple this application and fora defition ofall bold items. For addtional help, call IRS Exempt Organizations Customer Aocount Services tol-roe at 1-877-829-5500. Visit our website at wwwwrirs.gov fo forms and pudications the required information and documents are not submitted wth payment ofthe appropriate tser fe, the appication may be returned toyou ‘tach additional sheets to this application if you need more space to answer fully. Put your nam ancl EIN on each sheet and idontiy each answer by Pat and ine number, Complete Parts |~XI of Form 1028 and submit only those Schedules (A through H) that apply to you. KEE identification of Applicant “| ull namo of ergenization (exacty as W appears a you organizing deoument} | 2 Jo Name (applicable) ‘Tho NH District Corporation % lc. 7.4 ‘3 Malling address (Number and siree) (oso instructions) Foom/Suite | 4 Empioyor Identification Number (IN) {North Laurel stroot a szsosat27 ity or town, sate oF county, and IP +4 ‘Win tho anno accountng pated ans 172) ichmond, Vigna 23220, = ‘6 Primary contact (ofce, director, trustee, or authorized representative) a Name: Margarot S. Alors a 7 Are you represented by an authorized representative, such as an altomey or accountant? provide the authorized representative's nama, and the name and addoss of the authorized Fepresentalive's fim. Include a completed Form 2848, Power of Attomey and Dacleration of FRoprosentative, with your application if you would lke Us to communicate with your representative. ‘SEE ATTACHMENT 4 @ Was a person who j= not one of your officers, drectors, wustees, employoos, or an authorized [1 Yes [2] No representative listed in ine 7, paid, or promised payment, to help plan, manage, or advise you about the structure of actives of your arganization, oF about you financial or tax matters? If "Yes," provide the person's name, the name and addrese of the person's firm, the amounts pal or promised to be paid, and describe that person's role. ‘Organization's website: 1b Cxganization’s emai (optional) 7 70 Geran organizations are not required to fie an infomation ratum (Fm 880 ot Form SB0-EZ) you Wo ae granted tax-exerpton, are you clang to be excused Irom fling Form 980 or Form 980-E27 i "ea," explain. See the isiuctions fora doscrption of organizations not raquird to fle Form 990 or Form 990-€2 “TI Date corprated a carporaton, or ormed oiher tar a corporation. (WMIOOYWYY) oy 7-28 7 2097 12 Were you formed under the laws ofa foreign county? Ties (a) No 1%," state the county For Paperwork Reduction At Nalice, aoe atructons. ‘Ga Nos Farm 1028 fon 122077)Fem 23 Paw. 122017) Namte_The NH District Corporation en spasuaray ae 2 janizational Structure Cae see ae ee axl corp an ncaprad mena ora STE TE See atructons, BO NOY fle this form unos you an chook "Yes" ones 1, 2,3 oF 4 “4 Are you a corporation? If “Yes,” attach a copy of your articles of incorporation showing certification of [Z] Yes [) No filing wth tho appropiate stato agency. Inde copies of any amendments fo your arcles and be sure thoy also show sat fing cortiicalon. SEE ATTACHMENT 2 2 Are you a bintod ability company (LLG)? W=Ves, atach a copy of your ana of organization showing LTVes (2 No Corifeaton a ting wth te appropiate ette agen. Ab, Hye adopted an operating agaemen tach a copy Icudo copies ot any amendments to your aces and be aur thoy show tte fing coricton Rafer to tha instructions fo chcumstances when an LG shou tats oum exemption application. [Aro you an unincorporated asoocition? Wf "Yes," atach a copy of your articles of asoocation, Constuton, or other snlar organizing document tat fs cated and inci atleast two stron Inatde signed and dated cops of any amendments. ‘re you a trust? "Yes allach a signed and dated apy of your Wost agreement. Indie signed ard CTVes (No ‘atod copies of any amendments. you been funded? No" explain how you are formed withowt anything of vale placedin st. Yes_ C1 No. Fave you adopted bylaws? If "Yes," attach a current copy showing date of adoption. if “No,” explain [7) Yes (| No how your ofiers, directors ot rstee ao selected. SEE ATTACHMENT 3 [EMI Required Provisions in Your Organizing Document “Tho foloning quesors ar desired to ans that wien you fe hs appa, your argariang document contains tho requred provisions tomeet he erganzatonal os rte sect S0(10) Uns you can check te boxes noth inas | ane, yer ongoring cossrank Sooo ot meet ha operational tes, DO NOT fle ts aplication uni you have amended your organizing document. Sort your ‘plona ard amended organizing dover tows fe caicaon you area corporation or an 0) wth Your appcaton 1 Saction S01(cK3) requires that your organizing document state your exempt purpose(s), such as charitable, folgiove, educattoncl andor eile purposes. Chock the box to confi that your eroarizig docunent meets this requirement. Dstrbe specicaly whare yout organizing cocument mest ths requirement uc a raferene> toa paticlr aril or ection in your organizing dooumert orto tho struction for exon purpose language Location of Purpose Clas (Page, Ate, and Paragraph, pag 1 Za Seaton SGoK) reqs that upon desouon of your orpnzaon your eraking asses wut bo used axchsaly CZ {or oxorpt purposes, such as chartabo, aious, ducati, andor sl purpoces. Chock tho box on ine 2210 ‘orf tal you rganzng document ots tis roquremort by expree proviso fro carbton of eoat upon ‘Gnwoksion. youre on sit aw for your casohon proiion, donot check te box on tne 2a anc go tobe 2c Ifyou check the box on ne 22, pect he lacation of your dsokiton clause Pago, Ate and Poragraoh. Danct completa tine 2c ¥ you chacked Box 2. Ale Vl, pes 23 = © See the instructions for information about the operation of state law in your particular state. Check this box ifyou = L) rely on operation of sat Infor your dasotton provision and indicat tho stale: Narrative Description of Your Actvilios SEE ATTACHMENT 4 srg an ice, db yup rm anh tin or De yo har a rad ao thslorratin sn rponoo fo cher pare of hs apptcaton, youmay summarize that orion fers fr ote spec arts fe {pptenfon for support cal Youray av lla vopreorialve cpus of ravsitr, bochurs, o' sanlrdocumets for aupporing Bu tothe raat, Romorber hal ths appleaton ie epproved be open fr pubic inspection. Terre, yournaatie lesen fates should be horough ad actrnte Rel to he naruto or heaton hal mst be ncaa in your description. BERT] _ Compensation and Other Financial Arangements With Your Oteare, Drectars, Tusa ‘nd Independent Contractors cS “a LSt he Manes aon ag adrensn of al of Your fer, deco: a Wiles: FY coh pan ib oa a {otal anrua! compensation, or proposed compensation, fr al sonics tothe organization, whether as anor, employe, oF ‘er postion. Uso actual figures, favalabe, Enter “none” no compensation i or wl be pai. adSionl space Is needed attach a separate set. Refer fo he traction for information on wha oinchade 25 commpansation te |e ag en Smart [sc ren, ex Receuiytenare 0 } sie Pret 110200 Fon TORE fos. 12-2077)er 028 122017) are: the NH Distt Corporation em ___sz-aesai27 Page 3 ‘Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees, Employees, ‘and Independent Contractors (Continued) — List the names, titles, and maling addrosses of each of your fie highest Compensated employees wo receive or wil receive ‘compensation of more than $50,000 per yoar. Use the actual figure, if avaliable, Refer to the instructions for information on hat to include as compensation. Do no include offlors, cractors, o trustees listed inline 1a. Comparanion amen Nae Teo ating eros fara acto ested © Lak the names, hamies of businesses, and mailing addresses of your five highest compensated independent contractors that racelve or wil receive compensation of more than $60,000 per year. Use the actual figure, if availabe, Refer to the instructions for information on what to include as compensation, ‘Comparaton ant Name. te Nang acon (arm stl rite) ‘The folowing "Yes" or "No" questions relate to past, present, or planned relationships, wansactions, oF agreommonts with your ofosr, rectors, trusteas, highest compensated employees, and highest compensatad independent contractors sted in ines ta, 1b, and 16. 2a Ao any of your officers, drecters, or trustoes related to each other through family or business [] Yes [ZNo relationships? If "Ves,” identi the Indviduals and explain the relationship. Do you have a business relationship with any of your officers, directors, or tustees other than through [] Yes thelr position as an ofc, dactor, or trustee? if "Yes," identiy the individuals and describe the business ralntionship with each of your officers, directors, or tustoos. © Avoany of your officers, directors, or trustees related to your highest compensated employees or highest [)Yes No ‘compensated independent contractors listed on fines 1b or te through family or business relationship? I os,” idontity th individuals and explain the relationship. 3a For sach of your officers, decors, vustees, highest componsated employees, and highest compensated dependent contractors listed on lines 1a, 1b, or 1c, attach a list showing their name, {uallfcations, avorage hours worked, and duties. SEE ATTACHMENT b Do any of your officers, directors, trustees, highest compensated employees, and highest compensated ("| Yes [2 No Independent contractors ist on lines ta, 1b, or 1c receive compensation from any other organizations, whether tax exempt or taxable, that are related to you through eomman control? If “Ves,” identity the Individuals, explain the relationship between you and the other organization, and describe the ‘compensation arangement, "In establishing the componsation for your officers, directors, trustees, highest compensated employees, ‘and highest compensated independant contractors listed on ines 1a, 1b, and tc, the folowing practices fare recommended, although thay are not required to obtain exemption. Answor "Yes" to al the practices NIA you use. ‘8 Doyou oF wil tho individuals that approve compensation arrangements folow a conflict of interest policy? [Yes [No bDoyou or will ou approve compensation arrangemants in advance of paying compensation? Yes [No © Doyou or will you document in wring the date and terms of approved compensation arrangements? «C1 Yes. [No Farm TORS Pros 12007)