FOR FISCAL YEAR BEGINNING ________________________

This application has three parts, complete only those part(s) which apply to your request for exemption.

PART I - APPLICATION FOR EXEMPTION PERTAINING TO LIMITED MISSION

(1) Please explain in detail the specific and limited segment of the population which your organization serves. Attach additional pages if necessary.

(2) Attach a copy of your Mission Statement, Articles of Agreement and By-Laws or other instrument of creation.

(3) Attach a list of the names and addresses of the officers and directors of the organization. Please specify the contact person and include his/her telephone number.

(4) Does your organization accept any individual(s) not meeting the criteria listed in response to question (1)? Yes _______________ No______________

If the answer is Yes, please explain the circumstances under which you accept these individuals.

(5) Does your organization provide any health care services?

Yes ____________ No_______________

If the answer is Yes, please explain the type of health care services provided.

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PART II - APPLICATION FOR EXEMPTION BASED ON FINANCIAL BURDEN

(1) Attach a copy of your Mission Statement, Articles of Agreement and By-Laws or other instrument of creation.

(2) Attach a list of the names and addresses of the officers and directors of the organization. Please specify the contact person and include his/her telephone number.

(3) Attach a copy of your form 990, audited financial statement, or other financial report for your most recent accounting period.

(4) Please explain why complying with the provisions of the community benefits law would result in a negative financial burden for your organization. Be specific. Please feel free to attach additional pages.

(5) Please explain why it is not possible for your organization to collaborate with other health care charitable trust(s) in conducting the community needs assessment and in preparing the community benefits plan. Be specific. Please feel free to attach additional pages.

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PART III - APPLICATION FOR EXEMPTION BASED ON ADMINISTRATIVE BURDEN

(1) Attach a copy of your Mission Statement, Articles of Agreement and By-Laws or other instrument of creation.

(2) Attach a list of the names and addresses of the officers and directors of the organization. Please specify the contact person and include his/her telephone number.

(3) Attach a copy of your form 990, audited financial statement, or other financial report for your most recent accounting period.

(4) Attach a copy of your organizational chart showing all paid positions, whether full or part-time; provide the average number of volunteer hours given to your organization on an annual basis and a summary of the duties performed by these volunteers.

(6) Please explain why complying with the provisions of the community benefits law would result in an administrative burden for your organization. Be specific. Please feel free to attach additional pages.

(7) Please explain why it is not possible for your organization to collaborate with other health care charitable trust(s) in conducting the community needs assessment and in preparing the community benefits plan. Be specific. Please feel free to attach additional pages.

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CERTIFICATION
(MUST BE SIGNED REGARDLESS OF WHICH CATEGORY OF EXEMPTION YOU ARE SEEKING)

I hereby certify that the foregoing information is true to the best of my knowledge and belief.

This form must be submitted to the Department of the Attorney General, Charitable Trusts Unit, 33 Capitol Street, Concord, NH 03301-6397.

For Office Use Only

DEPARTMENT OF ATTORNEY GENERAL
CHARITABLE TRUSTS DIVISION

The foregoing request for exemption from the provisions of the community benefits law is hereby GRANTED/DENIED.

Reason for Denial:

DATE:_____________________