Free Applicant Name - Kansas

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

Applicant Name: ________________________ Docket No.:_____________________________

Addition to Exemption Application K.S.A. 79-201b Second (Adult Care Homes) K.S.A. 79-201b Third (Private Children's Homes) K.S.A. 79-201b Fifth (Elderly Housing) K.S.A. 79-201b Sixth (Licensed Group Housing) 1. 2. 3. 4.

Name of organization. _______________________________________________________________________________ Name and address of related organization(s). _______________________________________________________________________________ Type of home operated, e.g. adult care home, private children's home, etc. _______________________________________________________________________________ Is the organization currently licensed to operate an adult care home, private children's home, etc.? _____No _____Yes (If "Yes", enclose a copy of the license.) If yes, how many beds does the organization operate? ____________ Does the organization charge an entrance fee? _____No _____Yes If "Yes", what is the policy for this fee (i.e., premature death, a resident leaves the home, etc.?) _______________________________________________________________________________ _______________________________________________________________________________

5.

6.

How does the organization handle those who are no longer able to pay for its services? _______________________________________________________________________________ _______________________________________________________________________________

7.

Does the organization accept Medicaid recipients? If so, how many? _______________________________________________________________________________

8.

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

Revised 07/08

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

9.

Enclose a copy of one of the following: The organization's last three years audited financial statements; A statement from a qualified professional that the organization charges fees for services which produce an amount which in the aggregate is less than the actual cost of operation of the home; or A statement from a qualified professional that the services are provided at the lowest feasible cost taking into consideration such items as reasonable depreciation, interest on indebtedness, acquisition costs and contributions to the organization are deductible under the Kansas Income Tax Act.

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