Free Applicant Name - Kansas

Addition to Exemption KSA 79-201 Ninth Page 1 of 2

Applicant Name: ________________________ Docket No. _____________________________

Addition to Exemption Application Humanitarian Service Provider K.S.A. 79-201 Ninth
1. Name of the community service organization. ______________________________________________________________________________ Name and address of related organizations. ______________________________________________________________________________ Are the directors compensated for the service as directors? _____No _____Yes If yes, indicate the nature of the compensation. ______________________________________________________________________________ ______________________________________________________________________________ 4. Do any of the members, officers, or directors have a financial interest in the property? _____No _____Yes What service or services are being offered to the community? ______________________________________________________________________________ ______________________________________________________________________________ 6. Is there a demonstrated need for these services to the general public? How did you determine that the services were needed in your community or area?

2.

3.

5.

(a)

Why is this service needed, i.e., how will the general public benefit from the service?

(b)

Do the services provided meet this need?

(c)

Do you provide services to the general public or to a specific class of beneficiaries?

(d)

Are there commercial businesses or other organizations in the community that offer services similar to those at issue? If so, list.

(e)

Will the service have a positive influence on the community? Please explain.

(f)

Submit a letter provided by community leaders, elected officials, or state agencies evidencing that there is a community need for this service.

Revised 5/07

Addition to Exemption KSA 79-201 Ninth Page 2 of 2

Enclose: a. b. c. A copy of the IRS designation letter showing exemption pursuant to I.R.C. §501(c)(3). A copy of the Articles of Incorporation and Bylaws if organization is organized not-forprofit. A copy of the Certificate of Good Standing issued by the Secretary of State demonstrating that the organization is currently active and in good standing.

VERIFICATION I, ________________________________, do solemnly swear or affirm that the information set forth herein is true and correct, to the best of my knowledge and belief. So help me God.

_______________________________________ Signature of Applicant _______________________________________ Printed Name and Title State of ____________________ County of __________________ ) )

This instrument was acknowledged before me on __________ by _______________________________.

Seal

_____________________________________ Signature of Notary Public

My appointment expires: ________________

Revised 5/07