Form

Application for Recognition of Exemption

1023

(Rev. October

OMS No. 1545-0056

Note: If exempt status is
approved, this
application will be open
for public inspection.

Under Section 501 (c)(3) of the Internal Revenue Code

2004)

Department of the Treasury
Internal Revenue Service

Use the instructions to complete this application and for a definition of all bold items. For additional help, call IRS Exempt
Organizations Customer Account Services toll-free at 1-877-829-5500. Visit our website at www.irs.gov
for forms and
publications. If the required information and documents are not submitted with payment of the appropriate user fee, the
application may be returned to you.
Attach additional sheets to this application if you need more space to answer fully. Put your name and EIN on each sheet and
identify each answer by Part and line number. Complete Parts I - XI of Form 1023 and submit only those Schedules (A through
H) that apply to you.

Identification
1

of Applicant

Full name of organization (exactly as it appears in your organizing

Center for Independent
3

Mailing

address

Avenuet

City or town, state or country,

Washinqtont
6

Room/Suite

NW

3rd Floor

and ZIP + 4

4 ErrPo,e-ldniticetia1

33-1137541

12
trustee, or authorized

representative)

Deborah T. Ashford

b Phone:

202/637-8646

c Fax: (optional)
7

Are you represented by an authorized representative, such as an attorney
provide the authorized representative's name, and the name and address
representative's firm. Include a completed Form 2848, Power of Attorney
Representative, with your application if you would like us to communicate

(See question
8

N..rrt:a'(8~

5 Month the annualaccountingperiodends (01-12)

D.C. 20036

Primary contact (officer, director,
a Name:

Media

(Number and street) (see instructions)

1625 Massachusetts

2 c/o Name (if applicable)

document)

202/637-5910

b Organization's

11

Date incorporated

12

Were you formed under the laws of a foreign
If "Yes," state the country.

ISA
1

No

0

Yes

IXJ

No

0

Yes

!Xl No

emaH: (optional)

Certain organizations are not required to file an information return (Form 990 or Form 99~EZ). If you
are granted tax-exemption, are you claiming to be excused from filing Form 990 or Form 990-EZ? If
"Yes," explain. See the instructions for a description of organizations not required to file Form 990 or
Form 990-EZ.
•

STF FED2129F

o

website:

10

For Paperwork

Yes

6 above)

Was a person who is not one of your officers, directors, trustees, employees, or an authorized
representative listed in line 7, paid, or promised payment, to help plan, manage, or advise you about
the structure or activities of your organization, or about your financial or tax matters? If "Yes:
provide the person's name, the name and address of the person's firm, the amounts paid or
promised to be paid, and describe that person's role.

9a Organization's

IX!

or accountant? If "Yes,"
of the authorized
and Declaration of
with your representative.

Reduction

if a corporation,

or formed, if other than a corporation.
country?

Act Notice, see page 24 of the instructions.

(MM/DDfYYYY)

05/01/2006

o Yes
Form

1023

IX!

No

(Rev. 10-2004)

 Form 1023 (Rev. 10·2004)

Name:

Center

for

Inde endent Media

EIN:

Or anizational
Structure
You must be a corporation (including a limited liability company), an unincorporated association,
(See instructions.) DO NOT file this form unless you can check "Yes" on lines 1, 2,3, or 4.

33 -1137541

2

Page

or a trust to be tax exempt.

1

Are you a corporation?
If "Yes," attach a copy of your articles of incorporation showing certification
of filing with the appropriate state agency. Include copies of any amendments to your articles and
be sure they also show state filing certification.
(See Attachment A)

5a

Yes

0

No

2

Are you a limited /iabilitycompany
(LLCP If 'Yes,' attach a copy of your articles of organiz.ation showing
certification of filing with the appropriate state agency. Also, if you adopted an operating agreement, attach
a copy. Include copies of any amendments to your articles and be sure they show state filing certification.
Refer to the instructions for circumstances when an LLC should not file its own exemption application.

0

Yes

[Xl

No

3

Are you an unincorporated
association?
If ·Yes: attach a copy of your articles of association,
constitution, or other similar organizing document that is dated and includes at least two signatures.
Include signed and dated copies of any amendments.

DYes

fZl

No

No

4a Are you a trust? If "Ves," attach a signed and dated copy of your trust agreement. Include signed
and dated copies of any amendments.
b Have you been funded? If "No," explain how you are formed without anything of value placed in trust.

DYes

5a

DYes

5a

o No

5

Have you adopted bylaws?
how your officers, directors,

ImJII

Required

Provisions

If "Yes," attach a current copy showing date of adoption.
or trustees are selected.
(See Attachment
in Your

Organizing

If "No," explain

A)

o

Yes

No

Document

The following questions are designed to ensure that when you file this application, your organizing document contains the required provisions
to meet the organizational test under section 501(c)(3).Unless you can check the boxes in both lines 1 and 2, your organizing document
does not meet the organizational test. DO NOT file this application until you have amended your organizing document. Submit your
original and amended organizing documents (showing state filing certification if you are a corporation or an LLC) with your application.
1

[Xl

Section 501 {c)(3) requires that your organizing document state your exempt purpose(s), such as charitable,
religious. educational, and/or scientific purposes. Check the box to confirm that your organizing document
meets this requirement. Describe specifically where your organizing document meets this requirement, such as
a reference to a particul~r article or section in your organi~ing document. Refer to the instructions for exempt
purpose language. Locallon of Purpose Clause (Page, ArtIcle, and Paragraph):
Pagp,
:>.rH ("1p TTT

2a Section 501(c)(3) requires that upon dissolution of your organization, your remaining assets must be used exclusively
for exempt purposes, such as charitable, religious, educational, andlor scientific purposes. Check the box on line 2a to
confirm that your organizing document meets this requirement by express provision for the distribution of assets upon
dissolution. If you rely on state law for your dissolution provision, do not check the box on line 2a and go to line 2c.
2b If you checked the box on line 2a, specify the location of your dissolution clause (Page, Article, and Paragraph).
Do not complete line 2c if you checked box 2a. Poge 4
ll.•..
HC'le
VTT.
P"'r"'~""-"ph
f'
2c See the instructions for information about the operation of state law in your particular state. Check this box if
you rely on operation of state law for your dissolution provision and indicate the state:

Iim:im

Narrative

Description

of Your

Activities

(See Attachment

5a

0

B)

Using an attachment, describe your past, present, and planned activities In a narrative. If you believe that you have already provided some of
this information in response to other parts of this application, you may summarize that information here and refer to the specific parts of the
application for supporting details. You may also attach representative copies of newsletters, brochures, or similar documents for supporting
details to this narrative. Remember that if this application is approved. it will be open for public inspection. Therefore, your narrative
description of activities should be thorough and accurate. Refer to the instructions for information that must be included in your description .
••.•.•
:F.Ti.
•. - •• ,...
----

Compensation
and Other Financial
Arrangements
Employees,
and Independent
Contractors

With

Your

Officers,

Directors,

Trustees,

1a List the names, titles. and mailing addresses of all of your officers, directors, and trustees. For each person listed, state their
total annual compensation. or proposed compensation, for all services to the organization, whether as an officer, employee, or
other position. Use actual figures, if available. Enter "none" if no compensation is or will be paid. If additional space is needed,
attach a separate sheet. Refer to the instructions for information on what to include as compensation.
Trtle

Name

David S. Bennahum

Compensation amount
(annual actual or estimate<l)

Mailing address

Chairperson, President,
Treasurer, Director

2..1..5.3.-<:a..J..i•.:(Ql;;Il.i.. •••. .s.t.l;;I.'l.~t;., • .11.6.0.::' ...
Washinaton

D.C.

$175,000

20008

1525 P St NW #1

Eric

Braverman

David Brock

Secretary,
Director

Director

w~shinq't'';n:''6:
3_~ J~.. r:!.' .•

c'.'" 20"0'0 5". -

0

~t~_e"~tJ,:fJ; ~.._.,","

Washinaton,

D.C.

0

20007

Form
STF FED2129F2

1023

(Rev. 10-2004)

 Form 1023 (Rev.10-2004)

Name:Center

for

Inde

endent

Media

Page 3

EIN:33-1137541

Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees,
Employees, and Independent Contractors (Continued)
b List the names, titles, and mailing addresses of each of your five highest compensated employees who receive or will
receive compensation
of more than $50,000 per year. Use the actual figure, if available. Refer to the instructions for
information on what to include as compensation. Do not include officers, directors, or trustees listed in line 1a.

Alexsandra

Savino

Proqram

Compensation
amount
(annual
actualor estimated)

Mailingaddress

Tille

Name

Director

J,,~?~.1<.i.~glJlti!1_.P.l_'!~~_~_______
WashinQton. D.C. 20005

--

----- -- .. --

................. --

--- .. ---.. ----_

.. --

$85, 000

........ - ........ -- -------

~...................

..

--

- ............

--- - .. ---- ...... -- ......... -

...... - ............

---- .•. - --

......

-- ....

c list the names, names of businesses, and mailing addresses of your five highest compensated independent
contractors
that receive or will receive compensation of more than $50,000 per year. Use the actual figure, if available. Refer to the
instructions for information on what to include as compensation.
Name

Title

Compensation
amount
(annualactualor estimated)

Mailingaddress

.·.- - .... - - ·- - ...·... .. .. .. ··....
-,"

N/A

- - - - - - .·- - - - ·.... - . ...- .- - - - - - ..- - ·- .·- - . .- - - ·- - - .- ··- - - - - ·- .... ·- - ·- - - - - - - - .·- - ..
.·.... - ·..·

· - - - ·- - - - - ··..-

The following ·Ves" or "No" questIons relate to past, present, or planned relationships, transactions, or agreements with your officers,
directors, trustees, highest compensated employees, and highest compensated independent contractors listed in Iines1a, 1b, and 1c.

0

Yes

!Xl

No

b Do you have a business relationship with any of your officers, directors, or trustees other than
through their position as an officer, director, or trustee? If "Yes," identify the individuals and describe
the business relationship with each of your officers, directors, or trustees.

0

Yes

!Xl

No

c Are any of your officers, directors, or trustees related to your highest compensated employees or
highest compensated independent contractors listed on lines 1b or 1c through family or business
relationships? If "Ves," identify the individuals and explain the relationship.

0

Yes

!Xl

No

0

Yes

!Xl

No

Yes
Yes
Yes

o No
o No
o No

2a Are any of your officers, directors, or trustees related to each other through family
relationshipS?
If ·Ves," identify the individuals and explain the relationship.

or business

3a For each of your officers, directors, trustees, highest compensated employees, and highest
compensated independent contractors listed on lines 1a, 1b, or 1c, attach a list showing their name,
qualifications, average hours worked, and duties.
See
Attachment
C.
b Do any of your officers, directors, trustees, highest compensated employees, and highest
compensated independent contractors listed on lines 1a, 1b, or 1c receive compensation from any
other organizations, whether tax exempt or taxable, that are related to you through common
control? If "Yes," identify the individuals, explain the relationship between you and the other
organization, and describe the compensation arrangement.
4

In establishing the compensation for your officers, directors, trustees, highest compensated
employees, and highest compensated independent contractors listed on lines 1a, 1b, and 1c, the
following practices are recommended, although they are not required to obtain exemption. Answer
"Ves" to all the practices you use.
a Do you or will the individuals that approve compensation arrangements follow a conflict of interest policy?
b Do you or will you approve compensation arrangements in advance of paying compensation?
c Do you or will you document in writing the date and terms of approved compensation arrangements?

5a
5a
!Xl

Form 1023 (Rev.10-2004)
STF FED2129F.3

 Form1023 (Rev.
10-2004)
Name:Center
for
Inde
endent
Media
EIN:33-1137541
Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees,
Employees, and Independent Contractors (Continued)

Page

4

d Do you or will you record ;n writing the decision made by each individual who decided or voted on
compensation arrangements?

fZJ

Yes

0

No

e Do you or will you approve compensation arrangements based on information about compensation paid by
similarly situated taxable or tax-exempt organizations for similar services, current compensation surveys
compiled by independent firms, or actual written offers from similarly situated organizations? Refer to the
instructions for Part V, lines 1a, 1b, and 1c, for information on what to include as compensation.

o:a

Yes

0

No

f Do you or will you record in writing both the information on which you relied to base your decision
and its source?

!Xl

Yes

0

No

0

No

9 If you answered "No' to any item on lines 4a through 4f, describe how you set compensation that is
reasonable for your officers, directors, trustees, highest compensated employees, and highest
compensated independent contractors listed in Part V, Jines 1a, 1b, and 1c.
5a Have you adopted a conflict of interest policy consistent with the sample conflict of interest policy
fZJ Yes
in Appendix A to the instructions? If "Yes: provide a copy of the policy and explain how the policy
has been adopted, such as by resolution of your governing board. If "No," answer lines 5b and 5c. By resolution
governing

board.

See Attachment

of the

D.

b What procedures will you follow to assure that persons who have a conflict of interest will not have
influence over you for setting their own compensation?
c What procedures will you follow to assure that persons who have a conflict of interest will not have
influence over you regarding business deals with themselves?
Note: A conflict of interest policy is recommended
Hospitals, see Schedule C, Section I, line 14.

though it is not required to obtain exemption.

0

Yes

b Do you or will you compensate any of your employees, other than your officers, directors" trustees,
or your five highest compensated employees who receive or will receive compensation or more than
$50,000 per year, through non-fixed payments, such as discretionary bonuses or revenue-based
payments? If "Yes," describe all non-fixed compensation arrangements, including how the amounts
are or will be determined, who is or will be eligible for such arrangements, whether you place or will
place a limitation on total compensation, and how you determine or will determine that you pay no
more than reasonable compensation for services. Referto the instructions for Part V, Jines 1a, 1b,
and 1c, for information on what to include as compensation.

0

Yes

7a Do you or will you purchase any goods, services, or assets from any of your officers, directors,
trustees, highest compensated employees, or highest compensated independent contractors listed in
lines 1a, 1b, or 1c? If "Yes: describe any such purchase that you made or intend to make, from
whom you make or will make such purchases, how the terms are or will be negotiated at ann's
length, and explain how you determine or will determine that you pay no more than fair market
value. Attach copies of any written contracts or other agreements relating to such purchases.

0

Yes

Iil

No

b Do you or will you sell any goods, services, or assets to any of your officers, directors, trustees,
highest compensated employees, or highest compensated independent contractors listed in lines 1a,
1b, or 1c? If "Yes," describe any such sales that you made or intend to make, to whom you make or
will make such sales, how the terms are or will be negotiated at arm's length, and explain how you
determine or will determine you are or will be paid at least fair market value. Attach copies of any
written contracts or other agreements relating to such sales.

0

Yes

IXI

No

0

Yes

5!i:l

No

0

Yes

5!i:l

No

6a Do you or will you compensate any of your officers, directors, trustees, highest compensated employees,
and highest compensated independent contractors listed in lines 1a, 1b, or 1c through non-fixed
payments, such as discretionary bonuses or revenue-based payments? If "Yes,· describe all non-fixed
compensation arrangements, including how the amounts are determined, who is eligible for such
arrangements, whether you place a limitation on total compensation, and how you determine or will
determine that you pay no more than reasonable compensation for services. Refer to the instructions for
Part V, lines 1a, 1b, and 1c, for information on what to include as compensation.

Sa Do you or will you have any leases, contracts, loans, or other agreements with your officers,
trustees, highest compensated employees, or highest compensated independent contractors
lines 1a, 1b, or 1c? If "Yes," provide the information requested in lines 8b through 8f.
b
c
d
e
f

directors,
listed in

Describe any written or oral arrangements that you made or intend to make.
Identify with whom you have or will have such arrangements.
Explain how the terms are or will be negotiated at arm's length.
Explain hoN you detemine you pay nc more than fair market value or you are paid at least fair market value.
Attach copies of any signed leases, contracts, loans, or other agreements relating to such arrangements.

9a Do you or will you have any leases, contracts, loans, or other agreements with any organization in
which any of your officers, directors, or trustees are also officers, directors, or trustees, or in which
any individual officer, director, or trustee owns more than a 35% interest? If "Yes: provide the
information requested in lines 9b through 9f.

Form1023 (Rev.
10-2004)
STF FED2129F4

 Name:Center for Independent
Media
EIN:33-ll3754l
Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees,
Employees, and Independent Contractors (Continued)

Form 1023 (Rev,10-20D4)

mm
b
c
d
e

Page

5

Describe any written or oral arrangements you made or intend to make.
Identify with whom you have or will have such arrangements.
Explain how the terms are or will be negotiated at arm's length.
Explain how you determine or will determine you pay no more than fair market value or that you are
paid at least fair marke,t value.

f Attach a copy of any signed leases, contracts, loans, or other agreements relating to such arrangements.

IiZmI!lI

Your Members and Other Individuals and Organizations That Receive Benefits From You

The following "Yes" or "No' questions relate to goods, services, and funds you provide to individuals and organizations
of your activities. Your answers should pertain to past, present, and planned activities. (See instructions.)

[i] Yes

0

No

IXl

Yes

0

No

1a In carrying out your exempt purposes, do you provide goods, services, or funds to individuals? If
"Yes," describe each program that provides goods, services, or funds to individualS.See Attachment

as part

E.

b In carrying out your exempt purposes, do you provide goods, services, or funds to organizations? If
"Yes," describe each program that provides goods, services, or funds to organizations. See Attachment

F,

2

Do any of your programs limit the provision of goods, services, or funds to a specific individual or
group of specific individuals? For example, answer "Yes," if goods, services, or funds are provided
only for a particular individual, your members, individuals who work for a particular employer, or
graduates of a particular school. If "Yes," explain the limitation and how recipients are selected for
each program.

0

Yes

[i] No

3

Do any individuals who receive goods, services, or funds through your programs have a family or
business relationship with any officer, director, trustee, or with any of your highest compensated
employees or highest compensated independent contractors listed in Part V, lines 1a, 1b. and 1c? If
"Yes," explain how these related individuals are eligible for goods, services, or funds,

0

Yes

!Xl No

Yes

lXI No

~

Your History

The following "Yes· or "No" questions

relate to your history. (See instructions.)

1

Are you a successor to another organization? Answer "Yes," if you have taken or will take over the
activities of another organization; you took over 25% or more of the fair market value of the net
assets of another organization; or you were established upon the conversion of an organization from
for-profit to non-profit status. If "Yes," complete Schedule G.

0

2

Are you submitting this application more than 27 months after the end of the month in which you
were legally formed? If "Yes," complete Schedule E.

DYes

IilmI!m]

Do you support or oppose

candidates

in political

campaigns

Check the appropriate

in any way? If "Yes," explain.

2a Do you attempt to influence legislatiorl? If "Yes," explain how you attempt to influence legislation
and complete line 2b. If "No," go to line 3a.
See Attachment
G.
b Have you made or are you making an election to have your legislative activities measured by
expenditures by filing Form 5768? If "Yes," attach a copy of the Form 5768 that was already filed or
attach a completed Form 5768 that you are filing with this application. If "No," describe whether your
attempts to influence legislation are a substantial part of your activities. include the time and money
spent on your attempts to influence legislation as compared to your total activities.
3a Do you or will you operate bingo or gaming activities? If "Yes," describe who conducts them, and
list all revenue received or expected to be received and expenses paid or expected to be paid in
operating these activities. Revenue and expenses should be provided for the time periods specified
in Part IX, Financial Data,
b Do you or will you enter into contracts or other agreements with individuals or organizations to
conduct bingo or gaming for you? If "Yes," describe any written or oral arrangements that you made
or intend to make, identify with whom you have or will have such arrangements, explain how the
terms are or will be negotiated at arm's length. and explain how you determine or will determine you
pay no more than fair market value or you will be paid at least fair market value. Attach copies or
any written contracts or other agreements relating to such arrangements.
c List the states and local jurisdictions,
conduct gaming or bingo.

!Xl

No

including Indian Reservations,

box. Your
DYes

[i] Yes

lXJ

Yes

o No
o No

DYes

IXl

No

DYes

lXI

No

in which you conduct or will
Form

STF FED2129F,5

No

Your Specific Activities

The following "Yes' or "No" questions relate to specific activities that you may conduct.
answers should pertain to past, present, and planned activities. (See instructions.)
1

IXI

1023

(Rev 10-2004)

 1023(Rev.10-2004)
Name:Center
for
rnde
endent
Media
EIN:33-1137541
Your 5 ecific Activities Continued
4a Do you or will you undertake fundra/sing? If "Ves," check all the tundra/sing programs you do or will
IiJ Yes
conduct. (See instructions.)
/Xl mail solicitations
/Xl phone solicitations
IXI email solicitations
IXI accept donations on your website
IXI personal solicitations
IXI receive donations tram another organization's website
vehicle, boat, plane, or similar donations
0 government grant solicitations
IXI foundation grant solicitations
0 Other

Form

Page

6

o

No

o

Attach a description of each fundraising program. See

At tachment

H.

b Do you or wlll you have written or oral contracts with any individuals or organizations to raise funds
for you? If "Ves: describe these activities. Include all revenue and expenses from these activities
and state who conducts them. Revenue and expenses should be provided for the time periods
specified in Part IX, Financial Data. Also, attach a copy of any contracts or agreements.
c Do you or will you engage in tundra/sing activities for other organizations? If "Ves,· describe these
arrangements. Include a description of the organizations for which you raise funds and attach copies
of all contracts or agreements.

0

Yes

[iJ

No

o

Yes

5a

No

Dyes

5a

No

o
o

Yes
Yes

iii No

o

Yes

IiJ

o

Yes

iii No

d list all states and local jurisdictions in which you conduct fundraising. For each state or local
jurisdiction listed, specify whether you fundraise for your own organization, you fundraise for another
organization. or another organization fundra/ses for you. See Attachment I.
e Do you or will you maintain separate accounts for any contributor under which the contributor has
the right to advise on the use or distribution offunds? Answer "Ves· if the donor may provide advice
on the types of investments, distributions from the types of investments, or the distribution from the
donor's contribution account. If ·Ves: describe this program, including the type of advice that may
be provided and submit copies of any written materials provided to donors.
5 Are you affiliated with a governmental unit? If ·Ves," explain.
6a Do you or will you engage in economic development? If 'Ves," describe your program.
b Describe in full who benefits from your economic development activities and how the activities
promote exempt purposes.
7a Do or will persons other than your employees or volunteers develop your facilities? If 'Ves," describe
each facility, the role of the developer. and any business or family relationship(s) between the
developer and your officers, directors, or trustees.
b Do or will persons other than your employees or volunteers manage your activities or facilities? If
"Ves," describe each activity and facility, the role of the manager, and any business or family
relationship(s) between the manager and your officers, directors, or trustees.

IiJ No

No

c If there is a business or family relationship between any manager or developer and your officers,
directors, or trustees, identify the individuals, explain the relationship, describe how contracts are
negotiated at arm's length so that you pay no more than fair market value, and submit a copy of any
contracts or other agreements.
8

Do you or will you enter into joint ventures, including partnerships or limited liability companies
treated as partnerships, in which you share profits and losses with partners other than section
501{c){3)organizations? If "Ves,· describe the activities of these joint ventures in which you
participate.

9a Are you applying for exemption as a childcare organization under section 501(k)? If "Yes.· answer
lines 9b through 9d. If "No," go to line 10.
b Do you provide child care so that parents or caretakers of children you care for can be gainfully
employed (see instructions)? If "No," explain how you qualify as a childcare organization described
in section 501(k).

10

Dyes

50

No

0

Yes

~

No

0

Yes

iii No

c Of the children for whom you provide child care, are 85% or more of them cared for by you to
enable their parents or caretakers to be gainfully employed (see instructions)? If "No," explain how
you qualify as a childcare organization described in section 501(k).

Dyes
N/A

o

No

d Are your services available to the general public? If "No," describe the specific group of people for
whom your activities are available. Also, see the instructions and explain how you qualify as a
childcare organization described in section 501(k).

o

o

No

Do you or will you publish, own, or have rights in music, literature, tapes, artworks, choreography,
scientific discoveries, or other intellectual property? If "Ves," explain. Describe who owns or will
own any copyrights. patents. or trademarks. whether fees are or will be charged, how the fees are
determined, and how any items are or will be produced, distributed, and marketed.

N/A
DYes

Form
STF FED2129F.6

Yes

IiJ No

1023 (Rev.10-2004)

 Name:Center for

Inde

endent

Media

EIN:33-1137541

Your S ecific Activities Continued
Do you or will you accept contributions of; real property; conservation easements; closely held
securities; intellectual property such as patents, trademarks, and copyrights; works of music or art;
licenses; royalties; automobiles, boats, planes, or other vehicles; or collectibles of any type? If 'Ves,"
describe each type of contribution, any conditions imposed by the donor on the contribution, and
any agreements with the donor regarding the contribution.

Page

7

0 Yes

5a

No

12a Do you or will you operate in a foreign country or countries? If "Ves,» answer lines 12b through
12d. If "No," go to line 13a.
b Name the foreign countries and regions within the countries in which you operate.
c Describe your operations in each country and region in which you operate.
d Describe how your operations in each country and region further your exempt purposes.

DYes

5a

No

13a Do you or will you make grants, loans, or other distributions to organization(s)?lf "Ves," answer lines
13b through 13g. If "No," go to line 14a.
b Describe how your grants, loans,or other distributions to organizationsfurtheryour exempt purposes.
c Do you have written contracts with each of these organizations?If "Yes," attach a copy of each contract.
d Identify each recipient organization and any relationship between you and the recipient organization.
e Describe the records you keep with respect to the grants, loans, or other distributions you make.
f Describe your selection process, including whether you do any of the following:
(i) Do you require an application form? If "Ves," attach a copy of the form.
(ii) Do you require a grant proposal? If "Ves," describe whether the grant proposal specifies your
responsibilities and those of the grantee, obligates the grantee to use the grant funds only for the
purposes for which the grant was made, provides for periodic written reports concerning the use
of grant funds, requires a final written report and an accounting of how grant funds were used,
and acknowledges your authority to withhold and/or recover grant funds in case such funds are,
or appear to be, misused.
g Describe your procedures for oversight of distributions that assure you the resources are used to
further your exempt purposes, including whether you require periodic and final reports on the use of
resources.

Dyes

5a

No

DYes

o

No

DYes
Dyes

o

o

No

DYes

[i:!

DYes

o Ves

o No
o No

o Yes

o

No

Dyes

o

No

11

14a Do you or will you make grants, loans, or other distributions to foreign organizations? If "Ves,"
answer lines 14b through 14f. If "No," go to line 15.
b Provide the name of each foreign organization, the country and regions within a country in which
each foreign organization operates, and describe any relationship you have with each foreign
organization.
c Does any foreign organization listed in line 14b accept contributions earmarked for a specific country
or specific organization? If "Ves," list all earmarked organizations or countries.
d Do your contributors know that you have ultimate authority to use contributions made to you at your
discretion for purposes consistent with your exempt purposes? If "Yes," describe how you relay this
information to contributors.
e Do you or will you make pre-grant inquiries about the recipient organization? If "Ves," describe these
inquiries, including whether you inquire about the recipient's financial status, its tax-exempt status
under the Internal Revenue Code, its ability to accomplish the purpose for which the resources are
provided, and other relevant information.
f

Do you or will you use any additional procedures to ensure that your distributions to foreign
organizations are used in furtherance of your exempt purposes? If "Ves," describe these procedures,
including site visits by your employees or compliance checks by impartial experts, to verify that grant
funds are being used appropriately.

Form

STF FED2129F7

1023

No

No

(Rev. 10-2004)

 Form 1023 (Rev. 10-2004)

Name:Center for

Inde

endent

Media

EIN:33-1137541

Your S ecific Activities Continued
Do you have a close connection with any organizations? If 'Yes," explain.
Are you applying for exemption as a cooperative hospital service organization under section
501(e)? If "Yes," explain.
17
18
19
20
21
22

Are you applying for exemption as a cooperative service organization of operating educational
organizations under section 501(f)? If "Yes," explain.
Are you applying for exemption as a charitable risk pool under section 501(n)?If "Yes: explain.
Do you or will you operate a school? If "Yes," complete Schedule B. Answer "Yes: whether you
operate a school as your main function or as a secondary activity.
Is your main function to provide hospital or medical care? If "Yes," complete Schedule C.
Do you or will you provide low-income housing or housing for the elderly or handicapped? If
"Yes," complete Schedule F.
Do you or will you provide scholarships, fellowships, educational loans, or other educational grants to
individuals, including grants for travel, study, or other similar purposes? If 'Yes: complete
Schedule H.
Note: Private foundations may use Schedule H to request advance approval of individual grant
procedures.

Form
STF FED2129F.8

Page

8

0
0

Yes
Yes

~
~

No
No

0

Yes

~

No

0
0

Yes

lXI No

Yes

~

0
0

Yes
Yes

lXI No
lXI No

0

Yes

lXI No

1023

No

(Rev. 10-2004)

 Form 1023(Rev.10-2004)

Name:Center

Financial Data

ee

for

attac

e

Inde

sc

endent
e

u

EIN:33-1137541

Media

Page

9

e

For purposes of this schedule, years in existence referto completed tax years. If in existence 4 or more years, complete the
schedule for the most recent 4 tax years. If in existence more than 1 year but less than 4 years, complete the statements for
each year in existence and provide projections of your likely revenues and expenses based on a reasonable and good faith
estimate of your future finances for a total of 3 years of financial information. If in existence less than 1 year, provide projections
of your likely revenues and expenses for the current year and the 2 following years, based on a reasonable and good faith
estimate of your future finances for a total of 3 years of financial information. (See instructions.)
A. Statement of Reve!1ues and Expenses
Type of revenue or expense

Currenttax Y811r

3 prior tax years or 2 succeeding tax years

(a) From
To

(b) From 1/)/07
To 12h1!07
1?/~1/nF.

(e) ProvideTotal for
(a)through (d)

(c) From l./.1-tO..8- (d) From
To
To
12/'1!nll

1 Gifts, grants, and

2
3
4
5
6
r/I
Q)

:s

c

Q)

contributions received (do not
include unusual grants)
Membershi fees received
Gross investment income
Net unrelated business
income
Taxes levied for our benefit

675,000
0
0

1,600,000

a

0

0
0

a

0.00
0.00

Value of services or facilities
furnished by a governmental
unit without charge (not
including the value of services
generally furnished to the
public without charge)

a

0

a

0.00

listed above or in lines 9-12
below (attach an itemized list)

0

~
a:: 7 Any revenue not otherwise

675,000.00
8 Total of lines 1 throu h 7
9 Gross receipts from admissions,
merchandise sold or services
performed, or fumishing of
facilities in any activity that is
related to your exempt
purposes (attachitemized list)
a
675,000.00
10 Total of lines 8 and 9
11 Net gain or loss on sale of
capital assets (attach
schedule and see instructions)
0
12 Unusual rants
13 Total Revenue
Add lines 10 through 12
14 Fundraisin ex enses
15 Contributions, gifts, grants.
and similar amounts paid out
(attach an itemized list)
16 Disbursements to or for the
benefit of members (attach an
itemized list)

a
a

0
1,600,000.00

2,000,000

4,275,000.00

0

0.00
0.00

a

0

a
2,000,000.00

0

0

1 600 000.00

2 000 000.00

0.00

0.00
4,275,000.00

0.00

4 275 000.00

0.00

0
0

0

0.00
0.00

675,000.00
30,000

1,600 000.00

2,000,000.00

80,000

100,000

a

0

0

0

a

0

0.00

4,275,000.00

:17 Compensation of officers,
r/I

c

18
~ 19
20
21
22
23
Gl

directors, and trustees
Other salaries and wa es
Interest ex ense
Oecu ane rent, utilities, etc.
De reciation and de letion
Professional fees
Any expense not otherwise
classified, such as program
services (attach itemized list)

24 Total Expenses
Add lines 14 through 23

116,667
56,667

175,000
355,000
0
36,000
0
76 000

175,000

378,400

845,000

1,146,300

650,234.00

1,567,000.00

1,888,300.00

a

18,000
0
50 500

355 000

0
36,000

a
76 000

0.00
Form 1023 (Rev.10.2004)

STF FE02129F.9

 Form 1023 (Rev. 10-2004)

Name:

Center

for

Independent

Media

fiN:

33 -1137541

Financial Data Continued
B. Balance Sheet (for your most recently completed tax year)

7

8
9
10
11
12
13
14
15
16
17
18
19

Cash
· .. ·.··
,
···.··,·····.················
Accounts receivable, net
,
Inventories
,
, .. ,
Bonds and notes receivable (attach an itemized list)
,
Corporate stocks (attach an itemized list)
,
,
,
Loans receivable (attach an itemized list)
Other investments (attach an itemized list)
,
,
Depreciable and depletable assets (attach an itemized list)
Land
,
,
,
Other assets (attach an itemized list)
Total Assets (add lines 1 through 10)
Liabilities
Accounts payable
,
Contributions, gifts, grants, etc. payable
Mortgages and notes payable (attach an itemized list)
Other liabilities (attach an itemized list)
Total Liabilities (add lines 12 through 15)
Fund Balances or Net Assets
Total fund balances or net assets
Total Liabilities and Fund Balances or Net Assets (add lines 16 and 17)

10

Year End:

(Whole dollars)

Assets
1
2
3
4
5
6

Page

1
2
3

..
.
.
.
.
.
.
.
.
.
.

11

.
.
.
.
.

12
13
14
15
16

.

17

o

4

5
6
7

8
9

o

10

o

o

o
18
Have there been any substantial changes in your assets or liabilities since the end of the period
DYes
rXJ No
shown above? If "Yes: explain.
Public Charity Status
Part X is designed to classify you as an organization that is either a private foundation or a public charity. Public charity status
is a more favorable tax status than private foundation status. If you are a private foundation, Part X is designed to further
determine whether you are a private operating foundation. (See instructions.)
.

IiZ!!I3

1a Are you a private foundation? If "Yes," go to line 1b. If "No," go to line 5 and proceed as instructed.
If you are unsure, see the instructions.
b As a private foundation, section 508(e)requires special provisions in your organizing document in
addition to those that apply to all organizations described in section 501(c)(3).Check the box to
confirm that your organizing document meets this requirement. whether by express provision or by
reliance on operation of state law. Attach a statement that describes specifically where your
organizing document meets this requirement. such as a reference to a particular article or section in
your organizing document or by operation of state law. See the instructions, including Appendix B,
for information about the special provisions that need to be contained in your organizing document.
Go to line 2.
2 Are you a private operating foundation? To be a private operating foundation you must engage
directly in the active conduct of charitable, religious, educational, and similar activities, as opposed
to indirectly carrying out these activities by providing grants to individuals or other organizations. If
"Yes," go to line 3. If "No: go to the signature section of Part XI.

0

0

Yes

rXJ No

3

Haveyou existed for one or more years?If "Yes," attach financial information showing that you are a private
operatingfoundation;go to the signaturesectionof Part XI. If "No," continueto line4.

0

Yes

rXJ No

4

Have you attached either (1) an affidavit or opinion of counsel, (including a written affidavit or opinion
from a certified public accountant or accounting firm with expertise regarding this tax law matter),
that sets forth facts concerning your operations and support to demonstrate that you are likely to
satisfy the requirements to be classified as a private operating foundation; or (2) a statement
describing your proposed operations as a private operating foundation?

0

Yes

!XI

5

If you answered "No' to line 1a, indicate the type of public charity status you are requesting by checking one of the choices below,
You may check only one box.
The organization is not a private foundation because it is:
509{a)(1)and 17D(b){1)(A)(i)-a church or a convention or association of churches. Complete and attach Schedule A.
0
509(a)(1)and 170(b)(1}(A){ii)-aschool. Complete and attach Schedule B.
0
509(a)(1)and 170(b)(1)(A}{iii)-a hospital, a cooperative hospital service organization, or a medical research
0
organization operated in conjunction with a hospital. Complete and attach Schedule C.
509(a)(3)-an organization supporting either one or more organizations described in line 5a through c, f, g, or h
0
or a publicly supported section 501(c)(4), (5), or (6) organization. Complete and attach Schedule D.

a
b
c
d

!Xl No

o

Form
STF FED2129F.10

Yes

1023

No

(Rev. 10-2004)

 Form 1023 {Rev. 10-2004)

Name:

Center for Independent Media

fIN:

33-1137541

Page

IimIEf

Public Charity Status (Continued)
e 509(a)(4)-an organization organized and operated exclusively for testing for public safety.
f 509(a)(1) and 170(b)(1)(A)(iv)-an organization operated for the benefit of a college or university that is owned or
operated by a governmental unit.
9 509(a)(1)and 170(b)(1)(A)(vi)-an organization that receives a substantial part of its financial support in the form
of contributions from publicly supported organizations, from a governmental unit, or from the general public.
h 509(a){2)-an organization that normally receives not more than one-third.of its financial support from gross
investment income and receives more than one-third of its financial support from contributions, membership
fees, and gross receipts from activities related to its exempt functions (subject to certain exceptions).

6

A publicly supported organization, but unsure if it is described in 5g or 5h. The organization would like the IRS to
decide the correct status.
If you checked box g, h, or i in question 5 above,you must requesteither an advance or a definitive ru/ingby
selecting one of the boxes below. Referto the instructionsto determinewhich type of rulingyou are eligible to receive.

a Request for Advance Ruling: By checking this box and signing the consent, pursuant to section 6501(c)(4) of
the Code you request an advance ruling and agree to extend the statute of limitations on the assessment of
excise tax under section 4940 of the Code. The tax will apply only if you do not establish public support status
at the end of the 5-year advance ruling period. The assessment period will be extended for the 5 advance ruling
years to 8 years, 4 months, and 15 days beyond the end of the first year. You have the right to refuse or limit
the extension to a mutually agreed-upon period of time or issue(s). Publication 1035, Extending the Tax
Assessment Period, provides a more detailed explanation of your rights and the consequences of the choices
you make. You may obtain Publication 1035 free of charge from the IRS web site at www.irs.gov or by calling
toll-free 1-800-829-3676. Signing this consent will not deprive you of any appeal rights to which you would
otherwise be entitled. If you decide not to extend the statute of limitations, you are not eligible for an advance
ruling.

11

0
0
!Xl

0
0

fXl

For Organization

David S. Bennahum
(Type or print name of signer)

Chairperson,

President

(Type or print title or authority of signer)

For Director, Exempt Organizations

By

Date

b Request for Definitive Ruling: Check this box jf you have completed one tax year of at least 8 full months and
you are requesting a definitive ruling. To confirm your public support status, answer line 6b(i) if you checked box
g in line 5 above. Answer line 6b(ii) if you checked box h in line 5 above. If you checked box i in line 5 above,
answer both lines 6b(i) and (ii).

0

(i) (a) Enter 2% of line 8, column (e)on Part IX-A. Statement of Revenues and Expenses.

(b) Attach a list showing the name and amount contributed by each person, company, or organization whose
gifts totaled more than the 2% amount. If the answer is "None," check this box.
(ii) (a) For each year amounts are included on lines 1, 2, and 9 of Part IX-A. Statement of Revenues and
Expenses, attach a list showing the name of and amount received from each disqualified person. If the
answer is "None," check this box.
(b) For each year amounts are included on line 9 of Part IX-A. Statement of Revenues and Expenses, attach
a list showing the name of and amount received from each payer, other than a disqualified person, whose
payments were more than the larger of (1) 1% of line 10, Part IX-A. Statement of Revenues and
Expenses. or (2) $5,000. If the answer is "None: check this box.
7

Did you receive any unusual grants during any of the years shown on Part IX-A. Statement of
Revenues and Expenses? If ·Yes,· attach a list including the name of the contributor, the date and
amount of the grant, a brief description of the grant, and explain why it is unusual.

Dyes

Form
STF FED2129F.11

1023

0

0

o
o No

(Rev. 10-2004)

 Form 1023

(Rev.
10-2004)

Name:Center for

Inde

endent

Media

Page12

EIN:33-1137541

User Fee Information
You must include a user fee payment with this application. It will not be processed without your paid user fee. If your average
annual gross receipts have exceeded or will exceed $10,000 annually over a 4-year period, you must submit payment of $500. If
your gross receipts have not exceeded or will not exceed $10,000 annually over a 4-year period, the required user fee payment
is $150. See instructions for Part XI, for a definition of gross receipts over a 4-year period. Your check or money order must be
made payable to the United States Treasury. User fees are subject to change. Check our website at www.irs.gov and type "User
Fee" in the keyword box, or call Customer Account Services at 1-877-829-5500 for current information.
1

2
3

0

Have your annual gross receipts averaged or are they expected to average not more than $10,000?
If "Yes: check the box on line 2 and enclose a user fee payment of $150 (Subject to change-see above),
If "No,· check the box on line 3 and enclose a user fee payment of $500 (Subject to change-see above).
Check the box if you have enclosed the reduced user fee payment of $150 (Subject to change).
Check the box if you have enclosed the user fee payment of $500 (Subject to change).

[il

Yes

No

0
QQ

I declare under the penalties of perjulY that I am authorized to sign this application on behalf of the above organization and that I have examined this
application, includi the accompa Ing schedules lmd attachments. and to the best of my knOWledgeit Is true, correct, and complete.

::~~se
Here

David

S. Bennahum

(Type or print name of slgner)

Chairperson,
(Type or print title or authority

Reminder: Send the completed

STF FED2129F.12

sjl-r/Of.
(0

e)

~~----

President
or signer)

Form 1023 Checklist with your filled-in-appJication.

Form

1023 (Rev.

10-2004)

 Center for Independent Media
Address:
1625 Massachusetts Avenue, N.W., 3rd Floor
Washington, D.C. 20036
ErN: 33-1137541
IRS Form 1023
Part II, Items 1 and 5

ATTACHMENT A

DECLARATION OF COMPLETENESS AND CORRECTNESS OF ATTACHED
ORGANIZATIONAL DOCUMENTS

The attached Articles of Incorporation and Bylaws of Center for
Independent Media (the "Center") are complete and correct copies of the
organizational documents which embody all the powers, principles, purposes,
functions and other provisions by which the organization currently governs itself.

\ \ \DC - 26937/0001 - 2306438 vI