Free 50-282 Application for Ambulatory Health Care Center Assistance Exemption - Texas



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50-282 (8-03/3) [11.183 Rule 9.415] APPLICATION FOR AMBULATORY HEALTH CARE CENTER ASSISTANCE EXEMPTION Appraisal district name Address YEAR Phone (area code and number) This application covers property you owned on January 1 of this year or acquired during this year. You must file the completed form between January 1 and April 30 of this year. If you acquire the property after January 1 of this year and wish to qualify for the exemption this year, you must apply before the first anniversary of the date you acquired the property, or before the first anniversary of the date any property was acquired after January 1. Be sure to attach any additional documents requested. If the chief appraiser grants the exemption, you do not need to reapply annually, but you must reapply if the chief appraiser requires you to do so, or if you want the exempti

50-282 (8-03/3) [11.183 Rule 9.415]

APPLICATION FOR AMBULATORY HEALTH CARE CENTER ASSISTANCE EXEMPTION
Appraisal district name Address

YEAR

Phone (area code and number)

This application covers property you owned on January 1 of this year or acquired during this year. You must file the completed form between January 1 and April 30 of this year. If you acquire the property after January 1 of this year and wish to qualify for the exemption this year, you must apply before the first anniversary of the date you acquired the property, or before the first anniversary of the date any property was acquired after January 1. Be sure to attach any additional documents requested. If the chief appraiser grants the exemption, you do not need to reapply annually, but you must reapply if the chief appraiser requires you to do so, or if you want the exemption to apply to property not listed in this application. You must notify the chief appraiser in writing if and when your right to this exemption ends. Return the completed form to the address above. Step 1: Name and address of organization
Name of organization Present mailing address City, town or post office, state, ZIP code Name of person preparing this application Driver's License, Personal I.D. Certificate, or Social Security Number*: Phone (area code and number) Title

Step 2: Answer these questions about the organization

Operator of organization (check appropriate box)

Individual

Corporation

Association

1. Is the association exempt from federal income taxation under Section 501(a), Internal Revenue Code of 1986, as an organization described by Section 501(c)(3)? ............................................................ Yes 2. In the past year has the association loaned funds to, borrowed funds from, sold property to or bought property from a shareholder, director or member of the association, or has a shareholder or member sold his interest in the association for a profit? .......................................... If "YES," attach a description of each transaction. For sales, give buyer, seller, price paid, value of the property sold and date of sale. For loans, give lender, borrower, amount borrowed, interest rate and term of loan. Attach a copy of note, if any.

No

Yes

No

3. Does the association provide assistance to ambulatory health care centers that provide medical care to individuals without regard to the individuals' ability to pay, including providing policy analysis, disseminating information, conducting continuing education, providing research, collecting and analyzing data, or providing technical assistance to the health care centers? ......... 4. Is the association funded wholly or partly, or assists ambulatory health care centers that are funded wholly or partly, by a grant under Section 330, Public Health Service Act (42 U.S.C. Section 254b), and its subsequent amendments?........................................................... 5. Does the association perform abortions or provide abortion referrals or provide assistance to ambulatory health care centers that perform abortions or provide abortion referrals? .................... 6. Does the association perform, or does its charter permit it to perform, any function other than ambulatory health care center assistance? ....................................................................................... If "YES," attach a statement describing the other functions in detail.

Yes

No

Yes

No

Yes

No

Yes

No

Attach a list of salaries and other compensation for services paid in the last year. Also list any funds distributed to members, shareholders or directors in the last year. In each case, give recipient's name, type of service rendered or reason for payment and amounts paid. Continue on Page 2

50-282 (8-03/3) - Page 2 (11.183)

Step 3: Answer these questions about the organization bylaws or charter

Attach a copy of the charter, bylaws or other documents adopted by the organization which govern its affairs, and answer the following questions.

1. Does the organization use its assets in providing its assistance to ambulatory health care center functions or assistance to ambulatory health care center functions of another organization?.........

Yes

No

2. Do these documents direct that on the discontinuance of the organization, the organization's assets are to be transferred to the state of Texas, to the United States, or to an educational, religious, charitable or other similar organization that is qualified for exemption under Section 501(c)(3), Internal Yes Revenue Code, as amended? ............................................................................................................ If "YES," give the page and paragraph numbers. Page ________ Paragraph ________

No

If "NO," do these documents direct that on discontinuance of the organization, the organization's assets are to be transferred to its members who have promised in their membership applications to immediately transfer them to the State of Texas, to the United States, or to an educational, religious, charitable or other similar organization that is qualified for exemption under Section 501(c)(3), Internal Yes Revenue Code, as amended?........................................................................................................... If "YES," give the page and paragraph numbers. Page ________ Paragraph ________

No

If "YES," was the two-step transfer required for the organization to qualify for exemption under Sec. 501(c)(3), Internal Revenue Code, as amended?.......................................................................

Yes

No

3. Does the organization operate, or does its charter permit it to operate, in such a manner as to permit the accural of profits, the distribution of profits or the realization of any other form of private gain? .......

Yes

No

Step 4: Describe your property

PROPERTY TO BE EXEMPT: Attach one Schedule A (REAL PROPERTY) form for EACH parcel of real property to be exempt. Attach one Schedule B (PERSONAL PROPERTY) form listing ALL personal property to be exempt. List only property owned by the organization.

Step 5: Sign the application

By signing this application, you designate the property described in the attached Schedules A and B as the property against which the exemption for ambulatory health care center assistance associations may be claimed in the appraisal district. You certify that this information is true and correct to the best of your knowledge and belief.
On behalf of (name of organization) Authorized signature Date Title

If you make a false statement on this application, you could be found guilty of a Class A misdemeanor or a state jail felony under Texas Penal Code Section 37.10.
* You are required to give us this information on this form, in order to perform tax related functions for this office. Section 11.43 of the Tax Code authorizes this office to request this information to determine tax compliance. The chief appraiser is required to keep the information confidential and not open to public inspection, except to appraisal office employees who appraise property and as authorized by Section 11.48(b), Tax Code.

50-282 (8-03/3) - Page 3 (11.183)

Schedule A: Description of real property Complete one Schedule A form for EACH parcel of improved and unimproved real property qualified for exemption. Attach all completed schedules to your application for exemption.
Name of owner Legal description of property Appraisal district account number (Optional): Describe the primary use of the property.

Date of acquisition of the property

Is this property reasonably necessary for operation of the association / organization?

Yes

No

List all other individuals and organizations that used this property in the past year, and give the requested information for each.
NAME DATES USED ACTIVITY RENT PAID, IF ANY

50-282 (8-03/3) - Page 4 (11.183)

Schedule B: Description of personal property List all tangible property to be exempt on this schedule. Attach all completed schedules to your application for exemption.
Name of owner

Is this property reasonably necessary for operation of the association / organization?

Yes

No

ITEM

LOCATION

File Size: 165.2 kB
Pages: 4
Date: July 17, 2005
File Format: PDF
State: Texas
Category: Tax Forms
Author: Lulu Gomez
Word Count: 1,207 Words, 8,251 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.window.state.tx.us/taxinfo/taxforms/50-282.pdf