Part III. Your Activities — 0122 Inst 1024 (PDF)

Reminder. Answer all questions in this part as they pertain to your past, present, and planned activities.

Line 1. Describe completely and in detail your past, present, and planned activities. Your narrative description of activities

501(c)(15) - Mutual Insurance Compa- nies or Associations. If you are applying under section 501(c)(15), provide the following in addition to your narrative description of activities:

Whether you're a member of a controlled group of corporations as defined in section 831(c)(2)(C)(ii). (Disregard section 1563(b)(2)(B) in determining whether the organization is a member of a controlled group.)

Note. You would be considered a member of a controlled group of corporations if you were not exempt from tax under section 501(a). In applying section 1563(a), use a “more than 50%” stock ownership test to determine whether the applicant or any other corporation is a member of a controlled group.

If you are a such a member, include in the following table the total amount received by you and all other members of the controlled group. If not, include only

document was adopted by t of at least two individuals.	the signatures should b	be thorough and accurate because the amounts that relate to you.
	(a) Current Year	3 Prior Tax Years	3 Prior Tax Years	3 Prior Tax Years
	From __________ To __________	(b) __________	(c) __________	(d) __________
1. Direct written premiums *
2. Reinsurance assumed **
3. Reinsurance ceded **
4. Net written premiums ((line 1 plus line 2) minus line 3)
1. In addition to other direct written premiums, include on line 1 the full amount of any prepaid or advance premium in the year the prepayment is received. For example, if a $5,000 premium for a 3-year policy was received in the current year, include the full $5,000 amount in the Current Year column. 2 and *3. If you entered an amount on line 2 or 3, upload a copy of the reinsurance agreement into which you have entered.

inured since the later of your date of formation or March 23, 2010;

No substantial part of your activities constitutes, or has constituted since the later of your date of formation or March 23, 2010, carrying on propaganda, or otherwise attempting to influence legislation; and

501(c)(29) - CO-OP Health Insurance Issuers. If you are applying under section 501(c)(29) as a qualified nonprofit health insurance issuer (QNHII), provide the following in addition to your narrative description of activities:

Upload a copy of both the Notice of Award issued by Centers for Medicare

and Medicaid Services (CMS) and the fully executed Loan Agreement with CMS.

The following representations:

Except to the extent allowed by section 1322(c)(4) of the Patient Protection and Affordable Care Act, no part of your net earnings inures to the benefit of any private shareholder or individual, or has so

Instructions for Form 1024 -5-

You do not participate or intervene in (including the publishing or distributing of statements) any political campaign on behalf of (or in opposition to) any candidate for public office, nor have you so participated or intervened since the later of your date of formation or March 23,

Line 2. National Taxonomy of Exempt Entities (NTEE) code. An NTEE code is a three-character series of letters and numbers that generally describe a type of organization. Enter the code from the list of NTEE codes, located in Appendix A, that best describes you. For more information and more detailed definitions of these codes developed by the National Center for Charitable Statistics (NCCS), visit the Urban Institute, NCCS website at nccs.urba.org.

NTEE codes are also used for

TIP purposes other than identification

of organizations described in section 501(a) or section 521. Therefore, all codes in the list don't necessarily correspond to a section 501(a) or section 521 purpose.

Line 3. Describe any money or time (whether volunteer or paid) you spent or will spend attempting to influence the selection, nomination, election, or appointment of any person to any federal, state, or local public office or to an office in a political organization.

Line 8. If you should cease operations as a tax-exempt organization, explain to whom your assets will be distributed.

Line 9. Answer “Yes” if you provide or will provide insurance through a third party or provide the insurance yourself.

Line 10. Answer “Yes” if you make grants, loans, or other distributions (such as goods) to a foreign organization. A relationship between you and the recipient organization includes the following situations.

You control the recipient organization, or it controls you through common officers, directors, or trustees, or through authority to approve budgets or expenditures.

directed in Executive Orders. As part of the comprehensive and sustained campaign against terrorist financing, all U.S. persons, including U.S.-based charities, are prohibited from dealing with persons (individuals and entities) identified as being associated with terrorism on OFAC's Specially Designated Nationals and Blocked Persons List (OFAC SDN List). Information about OFAC sanction programs and the OFAC SDN List are available at treasury.gov/ ofac . If you make grants, loans, distributions, or you provide goods or services to a foreign organization or engage in activities in a foreign country, you are responsible to know whether an OFAC sanctions program applies and whether your activities require a license from OFAC to engage in a transaction that otherwise would be prohibited.