Free Applicant Name - Kansas

Addition to Exemption K.S.A. 79-201b First Page 1 of 2

Applicant Name: ________________________ Docket No.:_____________________________

Addition to Exemption Application K.S.A. 79-201b First (Hospitals) 1.

Name of organization. _______________________________________________________________________________

2.

Name and address of related organization(s). _______________________________________________________________________________

3.

Is the organization currently licensed to operate a hospital or psychiatric hospital? _____No _____Yes (If "Yes", enclose a copy of the applicable license.)

4.

If the subject property is used for hospital purposes by a hospital, psychiatric hospital, or public hospital authority, what types of services are provided and what hours are the services offered? _______________________________________________________________________________ _______________________________________________________________________________

5.

If the subject property is used by more than one organization, provide the names of the other organizations that use the property and explain in detail the uses of the property by the other organizations. _______________________________________________________________________________ _______________________________________________________________________________

6.

Enclose the following documentation: A copy of the Articles of Incorporation and Bylaws of the organization. A copy of the Certificate of Good Standing issued by the Kansas Secretary of State demonstrating that the organization is currently active and in good standing. A copy of the IRS designation letter showing exemption pursuant to I.R.C. §501(c)(3). A copy of the license issued by the proper licensing authority, if applicable.

Revised 07/08

Addition to Exemption K.S.A. 79-201b First Page 2 of 2

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 07/08