Application for Recognition of Exemption

Transcription

1 Form 123 (Rev. June 26) Department of the Treasury Internal Revenue Servie Appliation for Reognition of Exemption Under Setion 51()(3) of the Internal Revenue Code OMB te: If exempt status is approved, this appliation will e open for puli inspetion. Use the instrutions to omplete this appliation and for a definition of all old items. For additional help, all IRS Exempt Organizations Customer Aount Servies toll-free at Visit our wesite at for forms and puliations. If the required information and douments are not sumitted with payment of the appropriate user fee, the appliation may e returned to you. Attah additional sheets to this appliation if you need more spae to answer fully. Put your name and EIN on eah sheet and identify eah answer y Part and line numer. Complete Parts I - XI of Form 123 and sumit only those Shedules (A through H) that apply to you. Part I Identifiation of Appliant 1 Full name of organization (exatly as it appears in your organizing doument) Tidepool Projet 2 /o Name (if appliale) 3 Mailing address (Numer and street) (see instrutions) Room/Suite 4 Employer Identifiation Numer (EIN) 555 Bryant St., # City or town, state or ountry, and ZIP Month the annual aounting period ends (1 12) Palo Alto, CA Primary ontat (offier, diretor, trustee, or authorized representative) a Name: Howard Look Phone: (65) Fax: (optional) 7 Are you represented y an authorized representative, suh as an attorney or aountant? If, provide the authorized representative s name, and the name and address of the authorized representative s firm. Inlude a ompleted Form 2848, Power of Attorney and Delaration of Representative, with your appliation if you would like us to ommuniate with your representative. 8 Was a person who is not one of your offiers, diretors, trustees, employees, or an authorized representative listed in line 7, paid, or promised payment, to help plan, manage, or advise you aout the struture or ativities of your organization, or aout your finanial or tax matters? If, provide the person s name, the name and address of the person s firm, the amounts paid or promised to e paid, and desrie that person s role. 9a Organization s wesite: tidepool.org Organization s (optional) info@tidepool.org 1 Certain organizations are not required to file an information return (Form 99 or Form 99-EZ). If you are granted tax-exemption, are you laiming to e exused from filing Form 99 or Form 99-EZ? If, explain. See the instrutions for a desription of organizations not required to file Form 99 or Form 99-EZ. 11 Date inorporated if a orporation, or formed, if other than a orporation. (MM/DD/YYYY) 8 / 3 / Were you formed under the laws of a foreign ountry? If, state the ountry. For Paperwork Redution At tie, see page 24 of the instrutions. Cat K Form 123 (Rev. 6-26)

2 Tidepool Projet 46 Form 123 (Rev. 6-26) Name: EIN: Page 3 Part V Compensation and Other Finanial Arrangements With Your Offiers, Diretors, Trustees, Employees, and Independent Contrators (Continued) List the names, titles, and mailing addresses of eah of your five highest ompensated employees who reeive or will reeive ompensation of more than $5, per year. Use the atual figure, if availale. Refer to the instrutions for information on what to inlude as ompensation. Do not inlude offiers, diretors, or trustees listed in line 1a. Name Title Mailing address Compensation amount (annual atual or estimated) List the names, names of usinesses, and mailing addresses of your five highest ompensated independent ontrators that reeive or will reeive ompensation of more than $5, per year. Use the atual figure, if availale. Refer to the instrutions for information on what to inlude as ompensation. Name Title Mailing address Compensation amount (annual atual or estimated) The following or questions relate to past, present, or planned relationships, transations, or agreements with your offiers, diretors, trustees, highest ompensated employees, and highest ompensated independent ontrators listed in lines 1a, 1, and 1. 2a Are any of your offiers, diretors, or trustees related to eah other through family or usiness relationships? If, identify the individuals and explain the relationship. 3a Do you have a usiness relationship with any of your offiers, diretors, or trustees other than through their position as an offier, diretor, or trustee? If, identify the individuals and desrie the usiness relationship with eah of your offiers, diretors, or trustees. Are any of your offiers, diretors, or trustees related to your highest ompensated employees or highest ompensated independent ontrators listed on lines 1 or 1 through family or usiness relationships? If, identify the individuals and explain the relationship. For eah of your offiers, diretors, trustees, highest ompensated employees, and highest ompensated independent ontrators listed on lines 1a, 1, or 1, attah a list showing their name, qualifiations, average hours worked, and duties. Do any of your offiers, diretors, trustees, highest ompensated employees, and highest ompensated independent ontrators listed on lines 1a, 1, or 1 reeive ompensation from any other organizations, whether tax exempt or taxale, that are related to you through ommon ontrol? If, identify the individuals, explain the relationship etween you and the other organization, and desrie the ompensation arrangement. 4 In estalishing the ompensation for your offiers, diretors, trustees, highest ompensated employees, and highest ompensated independent ontrators listed on lines 1a, 1, and 1, the following praties are reommended, although they are not required to otain exemption. Answer to all the praties you use. a Do you or will the individuals that approve ompensation arrangements follow a onflit of interest poliy? Do you or will you approve ompensation arrangements in advane of paying ompensation? Do you or will you doument in writing the date and terms of approved ompensation arrangements? Form 123 (Rev. 6-26)

3 Tidepool Projet Form 123 (Rev. 6-26) Name: EIN: Page 4 Part V Compensation and Other Finanial Arrangements With Your Offiers, Diretors, Trustees, Employees, and Independent Contrators (Continued) d e f g 5a Do you or will you reord in writing the deision made y eah individual who deided or voted on ompensation arrangements? Do you or will you approve ompensation arrangements ased on information aout ompensation paid y similarly situated taxale or tax-exempt organizations for similar servies, urrent ompensation surveys ompiled y independent firms, or atual written offers from similarly situated organizations? Refer to the instrutions for Part V, lines 1a, 1, and 1, for information on what to inlude as ompensation. Do you or will you reord in writing oth the information on whih you relied to ase your deision and its soure? If you answered to any item on lines 4a through 4f, desrie how you set ompensation that is reasonale for your offiers, diretors, trustees, highest ompensated employees, and highest ompensated independent ontrators listed in Part V, lines 1a, 1, and 1. Have you adopted a onflit of interest poliy onsistent with the sample onflit of interest poliy in Appendix A to the instrutions? If, provide a opy of the poliy and explain how the poliy has een adopted, suh as y resolution of your governing oard. If, answer lines 5 and 5. What proedures will you follow to assure that persons who have a onflit of interest will not have influene over you for setting their own ompensation? What proedures will you follow to assure that persons who have a onflit of interest will not have influene over you regarding usiness deals with themselves? te: A onflit of interest poliy is reommended though it is not required to otain exemption. Hospitals, see Shedule C, Setion I, line 14. 6a Do you or will you ompensate any of your offiers, diretors, trustees, highest ompensated employees, and highest ompensated independent ontrators listed in lines 1a, 1, or 1 through non-fixed payments, suh as disretionary onuses or revenue-ased payments? If, desrie all non-fixed ompensation arrangements, inluding how the amounts are determined, who is eligile for suh arrangements, whether you plae a limitation on total ompensation, and how you determine or will determine that you pay no more than reasonale ompensation for servies. Refer to the instrutions for Part V, lines 1a, 1, and 1, for information on what to inlude as ompensation. Do you or will you ompensate any of your employees, other than your offiers, diretors, trustees, or your five highest ompensated employees who reeive or will reeive ompensation of more than $5, per year, through non-fixed payments, suh as disretionary onuses or revenue-ased payments? If, desrie all non-fixed ompensation arrangements, inluding how the amounts are or will e determined, who is or will e eligile for suh arrangements, whether you plae or will plae a limitation on total ompensation, and how you determine or will determine that you pay no more than reasonale ompensation for servies. Refer to the instrutions for Part V, lines 1a, 1, and 1, for information on what to inlude as ompensation. 7a Do you or will you purhase any goods, servies, or assets from any of your offiers, diretors, trustees, highest ompensated employees, or highest ompensated independent ontrators listed in lines 1a, 1, or 1? If, desrie any suh purhase that you made or intend to make, from whom you make or will make suh purhases, how the terms are or will e negotiated at arm s length, and explain how you determine or will determine that you pay no more than fair market value. Attah opies of any written ontrats or other agreements relating to suh purhases. Do you or will you sell any goods, servies, or assets to any of your offiers, diretors, trustees, highest ompensated employees, or highest ompensated independent ontrators listed in lines 1a, 1, or 1? If, desrie any suh sales that you made or intend to make, to whom you make or will make suh sales, how the terms are or will e negotiated at arm s length, and explain how you determine or will determine you are or will e paid at least fair market value. Attah opies of any written ontrats or other agreements relating to suh sales. 8a Do you or will you have any leases, ontrats, loans, or other agreements with your offiers, diretors, trustees, highest ompensated employees, or highest ompensated independent ontrators listed in lines 1a, 1, or 1? If, provide the information requested in lines 8 through 8f. d e f Desrie any written or oral arrangements that you made or intend to make. Identify with whom you have or will have suh arrangements. Explain how the terms are or will e negotiated at arm s length. Explain how you determine you pay no more than fair market value or you are paid at least fair market value. Attah opies of any signed leases, ontrats, loans, or other agreements relating to suh arrangements. 9a Do you or will you have any leases, ontrats, loans, or other agreements with any organization in whih any of your offiers, diretors, or trustees are also offiers, diretors, or trustees, or in whih any individual offier, diretor, or trustee owns more than a 35% interest? If, provide the information requested in lines 9 through 9f. Form 123 (Rev. 6-26)

4 Form 123 (Rev. 6-26) Name: Tidepool Projet EIN: Page 5 Part V Compensation and Other Finanial Arrangements With Your Offiers, Diretors, Trustees, Employees, and Independent Contrators (Continued) d e f Desrie any written or oral arrangements you made or intend to make. Identify with whom you have or will have suh arrangements. Explain how the terms are or will e 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 market value. Attah a opy of any signed leases, ontrats, loans, or other agreements relating to suh arrangements. Part VI Your Memers and Other Individuals and Organizations That Reeive Benefits From You The following or questions relate to goods, servies, and funds you provide to individuals and organizations as part of your ativities. Your answers should pertain to past, present, and planned ativities. (See instrutions.) 1a 2 In arrying out your exempt purposes, do you provide goods, servies, or funds to individuals? If, desrie eah program that provides goods, servies, or funds to individuals. In arrying out your exempt purposes, do you provide goods, servies, or funds to organizations? If, desrie eah program that provides goods, servies, or funds to organizations. Do any of your programs limit the provision of goods, servies, or funds to a speifi individual or group of speifi individuals? For example, answer, if goods, servies, or funds are provided only for a partiular individual, your memers, individuals who work for a partiular employer, or graduates of a partiular shool. If, explain the limitation and how reipients are seleted for eah program. 3 Do any individuals who reeive goods, servies, or funds through your programs have a family or usiness relationship with any offier, diretor, trustee, or with any of your highest ompensated employees or highest ompensated independent ontrators listed in Part V, lines 1a, 1, and 1? If, explain how these related individuals are eligile for goods, servies, or funds. Part VII Your History The following or questions relate to your history. (See instrutions.) 1 Are you a suessor to another organization? Answer, if you have taken or will take over the ativities of another organization; you took over 25% or more of the fair market value of the net assets of another organization; or you were estalished upon the onversion of an organization from for-profit to non-profit status. If, omplete Shedule G. 2 Are you sumitting this appliation more than 27 months after the end of the month in whih you were legally formed? If, omplete Shedule E. Part VIII Your Speifi Ativities The following or questions relate to speifi ativities that you may ondut. Chek the appropriate ox. Your answers should pertain to past, present, and planned ativities. (See instrutions.) 1 Do you support or oppose andidates in politial ampaigns in any way? If, explain. 2a Do you attempt to influene legislation? If, explain how you attempt to influene legislation and omplete line 2. If, go to line 3a. Have you made or are you making an eletion to have your legislative ativities measured y expenditures y filing Form 5768? If, attah a opy of the Form 5768 that was already filed or attah a ompleted Form 5768 that you are filing with this appliation. If, desrie whether your attempts to influene legislation are a sustantial part of your ativities. Inlude the time and money spent on your attempts to influene legislation as ompared to your total ativities. 3a Do you or will you operate ingo or gaming ativities? If, desrie who onduts them, and list all revenue reeived or expeted to e reeived and expenses paid or expeted to e paid in operating these ativities. Revenue and expenses should e provided for the time periods speified in Part IX, Finanial Data. Do you or will you enter into ontrats or other agreements with individuals or organizations to ondut ingo or gaming for you? If, desrie any written or oral arrangements that you made or intend to make, identify with whom you have or will have suh arrangements, explain how the terms are or will e negotiated at arm s length, and explain how you determine or will determine you pay no more than fair market value or you will e paid at least fair market value. Attah opies or any written ontrats or other agreements relating to suh arrangements. List the states and loal jurisditions, inluding Indian Reservations, in whih you ondut or will ondut gaming or ingo. Form 123 (Rev. 6-26)

5 Form 123 (Rev. 6-26) Name: Tidepool Projet EIN: Page 6 Part VIII Your Speifi Ativities (Continued) 4a Do you or will you undertake fundraising? If, hek all the fundraising programs you do or will ondut. (See instrutions.) mail soliitations soliitations personal soliitations vehile, oat, plane, or similar donations foundation grant soliitations Attah a desription of eah fundraising program. phone soliitations aept donations on your wesite reeive donations from another organization s wesite government grant soliitations Other Do you or will you have written or oral ontrats with any individuals or organizations to raise funds for you? If, desrie these ativities. Inlude all revenue and expenses from these ativities and state who onduts them. Revenue and expenses should e provided for the time periods speified in Part IX, Finanial Data. Also, attah a opy of any ontrats or agreements. Do you or will you engage in fundraising ativities for other organizations? If, desrie these arrangements. Inlude a desription of the organizations for whih you raise funds and attah opies of all ontrats or agreements. d List all states and loal jurisditions in whih you ondut fundraising. For eah state or loal jurisdition listed, speify whether you fundraise for your own organization, you fundraise for another organization, or another organization fundraises for you. e Do you or will you maintain separate aounts for any ontriutor under whih the ontriutor has the right to advise on the use or distriution of funds? Answer if the donor may provide advie on the types of investments, distriutions from the types of investments, or the distriution from the donor s ontriution aount. If, desrie this program, inluding the type of advie that may e provided and sumit opies of any written materials provided to donors. 5 6a 7a Are you affiliated with a governmental unit? If, explain. Do you or will you engage in eonomi development? If, desrie your program. Desrie in full who enefits from your eonomi development ativities and how the ativities promote exempt purposes. Do or will persons other than your employees or volunteers develop your failities? If, desrie eah faility, the role of the developer, and any usiness or family relationship(s) etween the developer and your offiers, diretors, or trustees. Do or will persons other than your employees or volunteers manage your ativities or failities? If, desrie eah ativity and faility, the role of the manager, and any usiness or family relationship(s) etween the manager and your offiers, diretors, or trustees. If there is a usiness or family relationship etween any manager or developer and your offiers, diretors, or trustees, identify the individuals, explain the relationship, desrie how ontrats are negotiated at arm s length so that you pay no more than fair market value, and sumit a opy of any ontrats or other agreements. 8 Do you or will you enter into joint ventures, inluding partnerships or limited liaility ompanies treated as partnerships, in whih you share profits and losses with partners other than setion 51()(3) organizations? If, desrie the ativities of these joint ventures in whih you partiipate. 1 9a Are you applying for exemption as a hildare organization under setion 51(k)? If, answer lines 9 through 9d. If, go to line 1. Do you provide hild are so that parents or aretakers of hildren you are for an e gainfully employed (see instrutions)? If, explain how you qualify as a hildare organization desried in setion 51(k). Of the hildren for whom you provide hild are, are 85% or more of them ared for y you to enale their parents or aretakers to e gainfully employed (see instrutions)? If, explain how you qualify as a hildare organization desried in setion 51(k). d Are your servies availale to the general puli? If, desrie the speifi group of people for whom your ativities are availale. Also, see the instrutions and explain how you qualify as a hildare organization desried in setion 51(k). Do you or will you pulish, own, or have rights in musi, literature, tapes, artworks, horeography, sientifi disoveries, or other intelletual property? If, explain. Desrie who owns or will own any opyrights, patents, or trademarks, whether fees are or will e harged, how the fees are determined, and how any items are or will e produed, distriuted, and marketed. Form 123 (Rev. 6-26)

6 Form 123 (Rev. 6-26) Name: Tidepool Projet EIN: Page 7 Part VIII Your Speifi Ativities (Continued) 11 Do you or will you aept ontriutions of: real property; onservation easements; losely held seurities; intelletual property suh as patents, trademarks, and opyrights; works of musi or art; lienses; royalties; automoiles, oats, planes, or other vehiles; or olletiles of any type? If, desrie eah type of ontriution, any onditions imposed y the donor on the ontriution, and any agreements with the donor regarding the ontriution. 12a d Do you or will you operate in a foreign ountry or ountries? If, answer lines 12 through 12d. If, go to line 13a. Name the foreign ountries and regions within the ountries in whih you operate. Desrie your operations in eah ountry and region in whih you operate. Desrie how your operations in eah ountry and region further your exempt purposes. 13a Do you or will you make grants, loans, or other distriutions to organization(s)? If, answer lines 13 through 13g. If, go to line 14a. Desrie how your grants, loans, or other distriutions to organizations further your exempt purposes. Do you have written ontrats with eah of these organizations? If, attah a opy of eah ontrat. d Identify eah reipient organization and any relationship etween you and the reipient organization. e Desrie the reords you keep with respet to the grants, loans, or other distriutions you make. f Desrie your seletion proess, inluding whether you do any of the following: (i) Do you require an appliation form? If, attah a opy of the form. (ii) Do you require a grant proposal? If, desrie whether the grant proposal speifies your responsiilities and those of the grantee, oligates the grantee to use the grant funds only for the purposes for whih the grant was made, provides for periodi written reports onerning the use of grant funds, requires a final written report and an aounting of how grant funds were used, and aknowledges your authority to withhold and/or reover grant funds in ase suh funds are, or appear to e, misused. g Desrie your proedures for oversight of distriutions that assure you the resoures are used to further your exempt purposes, inluding whether you require periodi and final reports on the use of resoures. 14a Do you or will you make grants, loans, or other distriutions to foreign organizations? If, answer lines 14 through 14f. If, go to line 15. Provide the name of eah foreign organization, the ountry and regions within a ountry in whih eah foreign organization operates, and desrie any relationship you have with eah foreign organization. d Does any foreign organization listed in line 14 aept ontriutions earmarked for a speifi ountry or speifi organization? If, list all earmarked organizations or ountries. Do your ontriutors know that you have ultimate authority to use ontriutions made to you at your disretion for purposes onsistent with your exempt purposes? If, desrie how you relay this information to ontriutors. e Do you or will you make pre-grant inquiries aout the reipient organization? If, desrie these inquiries, inluding whether you inquire aout the reipient s finanial status, its tax-exempt status under the Internal Revenue Code, its aility to aomplish the purpose for whih the resoures are provided, and other relevant information. f Do you or will you use any additional proedures to ensure that your distriutions to foreign organizations are used in furtherane of your exempt purposes? If, desrie these proedures, inluding site visits y your employees or ompliane heks y impartial experts, to verify that grant funds are eing used appropriately. Form 123 (Rev. 6-26)

7 Tidepool Projet 46 Form 123 (Rev. 6-26) Name: EIN: Page 8 Part VIII Your Speifi Ativities (Continued) 15 Do you have a lose onnetion with any organizations? If, explain Are you applying for exemption as a ooperative hospital servie organization under setion 51(e)? If, explain. Are you applying for exemption as a ooperative servie organization of operating eduational organizations under setion 51(f)? If, explain. Are you applying for exemption as a haritale risk pool under setion 51(n)? If, explain. Do you or will you operate a shool? If, omplete Shedule B. Answer, whether you operate a shool as your main funtion or as a seondary ativity. Is your main funtion to provide hospital or medial are? If, omplete Shedule C. Do you or will you provide low-inome housing or housing for the elderly or handiapped? If, omplete Shedule F. 22 Do you or will you provide sholarships, fellowships, eduational loans, or other eduational grants to individuals, inluding grants for travel, study, or other similar purposes? If, omplete Shedule H. te: Private foundations may use Shedule H to request advane approval of individual grant proedures. Form 123 (Rev. 6-26)

8 Tidepool Projet 46 Form 123 (Rev. 6-26) Name: EIN: Page 9 Part IX Finanial Data For purposes of this shedule, years in existene refer to ompleted tax years. If in existene 4 or more years, omplete the shedule for the most reent 4 tax years. If in existene more than 1 year ut less than 4 years, omplete the statements for eah year in existene and provide projetions of your likely revenues and expenses ased on a reasonale and good faith estimate of your future finanes for a total of 3 years of finanial information. If in existene less than 1 year, provide projetions of your likely revenues and expenses for the urrent year and the 2 following years, ased on a reasonale and good faith estimate of your future finanes for a total of 3 years of finanial information. (See instrutions.) Revenues Expenses A. Statement of Revenues and Expenses Type of revenue or expense Current tax year 3 prior tax years or 2 sueeding tax years Gifts, grants, and ontriutions reeived (do not inlude unusual grants) Memership fees reeived Gross investment inome Net unrelated usiness inome Taxes levied for your enefit Value of servies or failities furnished y a governmental unit without harge (not inluding the value of servies generally furnished to the puli without harge) Any revenue not otherwise listed aove or in lines 9 12 elow (attah an itemized list) Total of lines 1 through 7 Gross reeipts from admissions, merhandise sold or servies performed, or furnishing of failities in any ativity that is related to your exempt purposes (attah itemized list) Total of lines 8 and 9 Net gain or loss on sale of apital assets (attah shedule and see instrutions) Unusual grants Total Revenue Add lines 1 through 12 Fundraising expenses Contriutions, gifts, grants, and similar amounts paid out (attah an itemized list) Disursements to or for the enefit of memers (attah an itemized list) Compensation of offiers, diretors, and trustees Other salaries and wages Interest expense Oupany (rent, utilities, et.) Depreiation and depletion Professional fees Any expense not otherwise lassified, suh as program servies (attah itemized list) Total Expenses Add lines 14 through 23 (a) From To 8/3/12 6/3/13 () From To 7/1/13 6/3/14 () From To 7/1/14 6/3/15 (d) From To (e) Provide Total for (a) through (d) 5, 1,, 1,, 2,5, 5, 1,, 1,, 2,5, 5, 1,, 1,, 2,5, 5, 1,, 1,, 2,5, 1,, 1,, 25, 25, 25, 2, 2, 5, 15, 15, 3, 1,24, 1,24, 123

9 Tidepool Projet Page 1 Finanial Data (Continued) B. Balane Sheet (for your most reently ompleted tax year) Year End: 6/3/13 Form 123 (Rev. 6-26) Name: EIN: Part IX Assets 1 Cash 2 Aounts reeivale, net 3 Inventories 4 Bonds and notes reeivale (attah an itemized list) 5 Corporate stoks (attah an itemized list) 6 Loans reeivale (attah an itemized list) 7 Other investments (attah an itemized list) 8 Depreiale and depletale assets (attah an itemized list) 9 Land 1 Other assets (attah an itemized list) 11 Total Assets (add lines 1 through 1) Liailities 12 Aounts payale 13 Contriutions, gifts, grants, et. payale 14 Mortgages and notes payale (attah an itemized list) 15 Other liailities (attah an itemized list) 16 Total Liailities (add lines 12 through 15) Fund Balanes or Net Assets 17 Total fund alanes or net assets 18 Total Liailities and Fund Balanes or Net Assets (add lines 16 and 17) 19 Have there een any sustantial hanges in your assets or liailities sine the end of the period shown aove? If, explain. Part X Puli Charity Status (Whole dollars) 51, 51, Part X is designed to lassify you as an organization that is either a private foundation or a puli harity. Puli harity status is a more favorale 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 instrutions.) 1, 1, 51, 5, 1a 2 Are you a private foundation? If, go to line 1. If, go to line 5 and proeed as instruted. If you are unsure, see the instrutions. As a private foundation, setion 58(e) requires speial provisions in your organizing doument in addition to those that apply to all organizations desried in setion 51()(3). Chek the ox to onfirm that your organizing doument meets this requirement, whether y express provision or y reliane on operation of state law. Attah a statement that desries speifially where your organizing doument meets this requirement, suh as a referene to a partiular artile or setion in your organizing doument or y operation of state law. See the instrutions, inluding Appendix B, for information aout the speial provisions that need to e ontained in your organizing doument. Go to line 2. Are you a private operating foundation? To e a private operating foundation you must engage diretly in the ative ondut of haritale, religious, eduational, and similar ativities, as opposed to indiretly arrying out these ativities y providing grants to individuals or other organizations. If, go to line 3. If, go to the signature setion of Part XI. 3 Have you existed for one or more years? If, attah finanial information showing that you are a private operating foundation; go to the signature setion of Part XI. If, ontinue to line 4. 4 Have you attahed either (1) an affidavit or opinion of ounsel, (inluding a written affidavit or opinion from a ertified puli aountant or aounting firm with expertise regarding this tax law matter), that sets forth fats onerning your operations and support to demonstrate that you are likely to satisfy the requirements to e lassified as a private operating foundation; or (2) a statement desriing your proposed operations as a private operating foundation? 5 a d If you answered to line 1a, indiate the type of puli harity status you are requesting y heking one of the hoies elow. You may hek only one ox. The organization is not a private foundation eause it is: 59(a)(1) and 17()(1)(A)(i) a hurh or a onvention or assoiation of hurhes. Complete and attah Shedule A. 59(a)(1) and 17()(1)(A)(ii) a shool. Complete and attah Shedule B. 59(a)(1) and 17()(1)(A)(iii) a hospital, a ooperative hospital servie organization, or a medial researh organization operated in onjuntion with a hospital. Complete and attah Shedule C. 59(a)(3) an organization supporting either one or more organizations desried in line 5a through, f, g, or h or a pulily supported setion 51()(4), (5), or (6) organization. Complete and attah Shedule D. Form 123 (Rev. 6-26)

10 Form 123 (Rev. 6-26) Name: EIN: Part X 6 e f g h i a Tidepool Projet Puli Charity Status (Continued) Page 11 59(a)(4) an organization organized and operated exlusively for testing for puli safety. 59(a)(1) and 17()(1)(A)(iv) an organization operated for the enefit of a ollege or university that is owned or operated y a governmental unit. 59(a)(1) and 17()(1)(A)(vi) an organization that reeives a sustantial part of its finanial support in the form of ontriutions from pulily supported organizations, from a governmental unit, or from the general puli. 59(a)(2) an organization that normally reeives not more than one-third of its finanial support from gross investment inome and reeives more than one-third of its finanial support from ontriutions, memership fees, and gross reeipts from ativities related to its exempt funtions (sujet to ertain exeptions). A pulily supported organization, ut unsure if it is desried in 5g or 5h. The organization would like the IRS to deide the orret status. If you heked ox g, h, or i in question 5 aove, you must request either an advane or a definitive ruling y seleting one of the oxes elow. Refer to the instrutions to determine whih type of ruling you are eligile to reeive. Request for Advane Ruling: By heking this ox and signing the onsent, pursuant to setion 651()(4) of the Code you request an advane ruling and agree to extend the statute of limitations on the assessment of exise tax under setion 494 of the Code. The tax will apply only if you do not estalish puli support status at the end of the 5-year advane ruling period. The assessment period will e extended for the 5 advane ruling years to 8 years, 4 months, and 15 days eyond 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). Puliation 135, Extending the Tax Assessment Period, provides a more detailed explanation of your rights and the onsequenes of the hoies you make. You may otain Puliation 135 free of harge from the IRS we site at or y alling toll-free Signing this onsent will not deprive you of any appeal rights to whih you would otherwise e entitled. If you deide not to extend the statute of limitations, you are not eligile for an advane ruling. Consent Fixing Period of Limitations Upon Assessment of Tax Under Setion 494 of the Internal Revenue Code For Organization /s/ Howard Look (Signature of Offier, Diretor, Trustee, or other authorized offiial) Howard Look 6/1/213 (Type or print name of signer) President and CEO (Type or print title or authority of signer) (Date) For IRS Use Only IRS Diretor, Exempt Organizations (Date) Request for Definitive Ruling: Chek this ox if you have ompleted one tax year of at least 8 full months and you are requesting a definitive ruling. To onfirm your puli support status, answer line 6(i) if you heked ox g in line 5 aove. Answer line 6(ii) if you heked ox h in line 5 aove. If you heked ox i in line 5 aove, answer oth lines 6(i) and (ii). (i) (ii) (a) Enter 2% of line 8, olumn (e) on Part IX-A. Statement of Revenues and Expenses. () Attah a list showing the name and amount ontriuted y eah person, ompany, or organization whose gifts totaled more than the 2% amount. If the answer is ne, hek this ox. (a) () For eah year amounts are inluded on lines 1, 2, and 9 of Part IX-A. Statement of Revenues and Expenses, attah a list showing the name of and amount reeived from eah disqualified person. If the answer is ne, hek this ox. For eah year amounts are inluded on line 9 of Part IX-A. Statement of Revenues and Expenses, attah a list showing the name of and amount reeived from eah payer, other than a disqualified person, whose payments were more than the larger of (1) 1% of line 1, Part IX-A. Statement of Revenues and Expenses, or (2) $5,. If the answer is ne, hek this ox. 7 Did you reeive any unusual grants during any of the years shown on Part IX-A. Statement of Revenues and Expenses? If, attah a list inluding the name of the ontriutor, the date and amount of the grant, a rief desription of the grant, and explain why it is unusual. Form 123 (Rev. 6-26)

11 Form 123 (Rev. 6-26) Name: EIN: Part XI Page 12 I delare under the penalties of perjury that I am authorized to sign this appliation on ehalf of the aove organization and that I have examined this appliation, inluding the aompanying shedules and attahments, and to the est of my knowledge it is true, orret, and omplete. Please Sign Here User Fee Information You must inlude a user fee payment with this appliation. It will not e proessed without your paid user fee. If your average annual gross reeipts have exeeded or will exeed $1, annually over a 4-year period, you must sumit payment of $75. If your gross reeipts have not exeeded or will not exeed $1, annually over a 4-year period, the required user fee payment is $3. See instrutions for Part XI, for a definition of gross reeipts over a 4-year period. Your hek or money order must e made payale to the United States Treasury. User fees are sujet to hange. Chek our wesite at and type User Fee in the keyword ox, or all Customer Aount Servies at for urrent information. 2 3 Have your annual gross reeipts averaged or are they expeted to average not more than $1,? If, hek the ox on line 2 and enlose a user fee payment of $3 (Sujet to hange see aove). If, hek the ox on line 3 and enlose a user fee payment of $75 (Sujet to hange see aove). Chek the ox if you have enlosed the redued user fee payment of $3 (Sujet to hange). Chek the ox if you have enlosed the user fee payment of $75 (Sujet to hange). /s/ Howard Look Tidepool Projet (Signature of Offier, Diretor, Trustee, or other authorized offiial) (Type or print name of signer) (Type or print title or authority of signer) Reminder: Send the ompleted Form 123 Cheklist with your filled-in-appliation. (Date) Howard Look 6/1/213 President and CEO Form 123 (Rev. 6-26)

12 Tidepool Projet Page 13 Shedule A. Churhes Form 123 (Rev. 6-26) Name: EIN: 1a Do you have a written reed, statement of faith, or summary of eliefs? If, attah opies of relevant douments. 2a Do you have a form of worship? If, desrie your form of worship. Do you have a formal ode of dotrine and disipline? If, desrie your ode of dotrine and disipline. Do you have a distint religious history? If, desrie your religious history. Do you have a literature of your own? If, desrie your literature. 3 Desrie the organization s religious hierarhy or elesiastial government. 4a 5a 6 7 8a Do you have regularly sheduled religious servies? If, desrie the nature of the servies and provide representative opies of relevant literature suh as hurh ulletins. What is the average attendane at your regularly sheduled religious servies? Do you have an estalished plae of worship? If, refer to the instrutions for the information required. Do you own the property where you have an estalished plae of worship? Do you have an estalished ongregation or other regular memership group? If, refer to the instrutions. How many memers do you have? Do you have a proess y whih an individual eomes a memer? If, desrie the proess and omplete lines 8 8d, elow. If you have memers, do your memers have voting rights, rights to partiipate in religious funtions, or other rights? If, desrie the rights your memers have. May your memers e assoiated with another denomination or hurh? d Are all of your memers part of the same family? 9 Do you ondut aptisms, weddings, funerals, et.? 1 11a Do you have a shool for the religious instrution of the young? Do you have a minister or religious leader? If, desrie this person s role and explain whether the minister or religious leader was ordained, ommissioned, or liensed after a presried ourse of study. Do you have shools for the preparation of your ordained ministers or religious leaders? 12 Is your minister or religious leader also one of your offiers, diretors, or trustees? Do you ordain, ommission, or liense ministers or religious leaders? If, desrie the requirements for ordination, ommission, or liensure. Are you part of a group of hurhes with similar eliefs and strutures? If, explain. Inlude the name of the group of hurhes. 15 Do you issue hurh harters? If, desrie the requirements for issuing a harter Did you pay a fee for a hurh harter? If, attah a opy of the harter. Do you have other information you elieve should e onsidered regarding your status as a hurh? If, explain. Form 123 (Rev. 6-26)

13 Tidepool Projet Page 14 Shedule B. Shools, Colleges, and Universities If you operate a shool as an ativity, omplete Shedule B Operational Information Form 123 (Rev. 6-26) Name: EIN: Setion I 1a 2a 3 Do you normally have a regularly sheduled urriulum, a regular faulty of qualified teahers, a regularly enrolled student ody, and failities where your eduational ativities are regularly arried on? If, do not omplete the remainder of Shedule B. Is the primary funtion of your shool the presentation of formal instrution? If, desrie your shool in terms of whether it is an elementary, seondary, ollege, tehnial, or other type of shool. If, do not omplete the remainder of Shedule B. Are you a puli shool eause you are operated y a state or sudivision of a state? If, explain how you are operated y a state or sudivision of a state. Do not omplete the remainder of Shedule B. Are you a puli shool eause you are operated wholly or predominantly from government funds or property? If, explain how you are operated wholly or predominantly from government funds or property. Sumit a opy of your funding agreement regarding government funding. Do not omplete the remainder of Shedule B. In what puli shool distrit, ounty, and state are you loated? Were you formed or sustantially expanded at the time of puli shool desegregation in the aove shool distrit or ounty? Has a state or federal administrative ageny or judiial ody ever determined that you are raially disriminatory? If, explain. Has your right to reeive finanial aid or assistane from a governmental ageny ever een revoked or suspended? If, explain. Do you or will you ontrat with another organization to develop, uild, market, or finane your failities? If, explain how that entity is seleted, explain how the terms of any ontrats or other agreements are negotiated at arm s length, and explain how you determine that you will pay no more than fair market value for servies. te. Make sure your answer is onsistent with the information provided in Part VIII, line 7a. 8 Do you or will you manage your ativities or failities through your own employees or volunteers? If, attah a statement desriing the ativities that will e managed y others, the names of the persons or organizations that manage or will manage your ativities or failities, and how these managers were or will e seleted. Also, sumit opies of any ontrats, proposed ontrats, or other agreements regarding the provision of management servies for your ativities or failities. Explain how the terms of any ontrats or other agreements were or will e negotiated, and explain how you determine you will pay no more than fair market value for servies. te. Answer if you manage or intend to manage your programs through your own employees or y using volunteers. Answer if you engage or intend to engage a separate organization or independent ontrator. Make sure your answer is onsistent with the information provided in Part VIII, line 7. Setion II Estalishment of Raially ndisriminatory Poliy Information required y Revenue Proedure Have you adopted a raially nondisriminatory poliy as to students in your organizing doument, ylaws, or y resolution of your governing ody? If, state where the poliy an e found or supply a opy of the poliy. If, you must adopt a nondisriminatory poliy as to students efore sumitting this appliation. See Puliation Do your rohures, appliation forms, advertisements, and atalogues dealing with student admissions, programs, and sholarships ontain a statement of your raially nondisriminatory poliy? 3 a If, attah a representative sample of eah doument. If, y heking the ox to the right you agree that all future printed materials, inluding wesite ontent, will ontain the required nondisriminatory poliy statement. Have you pulished a notie of your nondisriminatory poliy in a newspaper of general irulation that serves all raial segments of the ommunity? (See the instrutions for speifi requirements.) If, explain. 4 Does or will the organization (or any department or division within it) disriminate in any way on the asis of rae with respet to admissions; use of failities or exerise of student privileges; faulty or administrative staff; or sholarship or loan programs? If, for any of the aove, explain fully. Form 123 (Rev. 6-26)

14 Part II, Question 1 ATTACHMENT TO FORM 123 APPLICATION FOR RECOGNITION OF EXEMPTION Tidepool Projet 555 Bryant St., #429 Palo Alto, CA 9431 EIN: Tidepool Projet was formerly known as GreenDot Diaetes. GreenDot Diaetes was inorporated as a nonprofit puli enefit orporation on August 3, 212. A true and orret opy of GreenDot Diaetes Artiles of Inorporation, ertified y the California Seretary of State, is attahed hereto as Exhiit A. On May 9, 213, the entity name GreenDot Diaetes was hanged to Tidepool Projet. A true and orret opy of the Certifiate of Amendment of Artiles of Inorporation is hereto attahed as Exhiit B. The entity may do usiness as Tidepool, Tidepool Projet, Tidepool Organization or Tidepool.org. Part II, Question 5 A true and orret opy of Tidepool s Bylaws are attahed hereto as Exhiit C. Part IV: Narrative Desription of Ativities of Tidepool A. Introdution Tidepool is a non-profit organization dediated to uilding an open software platform and appliations that will help people with diaetes manage their disease etter and lead to healthier outomes. B. Bakground Diaetes is a hroni disease for whih management requires ongoing olletion, integration, and analysis of health related information in order to optimize treatment and effet ehavior hanges. Current for-profit solutions for management of diaetes data and information are losed, vertial and proprietary. This impedes innovation and prevents people with diaetes from reeiving the est are and treatment possile. For example, urrent systems do not allow patients and their dotors to view data from gluose monitors and insulin pumps made y different manufaturers in a oherent,

15 integrated fashion. This makes it very hallenging, if not impossile, for dotors and patients to analyze the information and optimize treatment regimens. C. Key Ativities Tidepool is developing a software platform and appliations that will allow dotors to provide the est possile are to their patients with diaetes. The ultimate goal of Tidepool is to help people with diaetes. Building an open software platform is our means to that end goal. The Tidepool platform will failitate data olletion and storage, foster open data and protool standards, and provide seure aess for patients and their health are providers. Our software solutions will make diaetes data aquisition, visualization and interpretation more seamless, intuitive and ationale. Our open platform will e valuale to liniians and researhers who are estalishing new software-driven treatments, as they will not need to reinvent the wheel. Tidepool will develop its software using an open development model, leveraging a virant, motivated open development ommunity. We will make our software and servies availale for free to other non-profit entities and researhers. We elieve that eing a nonprofit and developing an open software platform is neessary to enourage the road adoption of the platform as well as to enourage adoption of open data and protool standards. Tidepool is urrently staffed y a small numer of volunteers inluding health are providers, diaetes speialists, software engineers, and usiness professionals. We are soliiting funding from philanthropi donors who share our desire for etter appliations and an open platform and data standards for diaetes are. We will hire a small staff of software developers to atalyze development efforts and to help organize the open development ommunity s efforts. Eventually, Tidepool intends to provide its software and servies to for-profit entities that wish to adopt the elements of the Tidepool platform. Fees to forprofit entities will e at fair market value, to e asertained at the time that we make the software and servies availale. Any revenue generated from these liensing ativities will e used to over operating expenses and redue the need to ondut ongoing philanthropi fundraising. Part V, Question 3a All urrent employees and offiers are volunteers and are not ompensated. As fundraising efforts proeed, ompensation for employees will e determined using

16 omparative analysis of other non-profit software development entities and will require oard ompensation ommittee approval. Howard Look, President and CEO Qualifiations: Howard previously served as VP of Software and User Experiene at TiVo, Pixar and Amazon.om/La126. He was also SVP of Consumer Appliations for Linden La, where he led a large open soure development projet. Howard has a daughter with type 1 diaetes. Duties: Howard will oversee all ativities for Tidepool, inluding fundraising, operations and software development. Compensation: Currently. Average hours per week worked for Tidepool: 4 Steve MCanne, PhD, Chief Tehnial Offier Qualifiations: Steve was CTO at Inktomi and founder and CTO at Rivered. Steve has a daughter with type 1 diaetes. Duties: Steve will serve as part-time CTO of Tidepool. Compensation: Currently. Average hours per week worked for Tidepool: 1 Dr. Saleh Adi Qualifiations: Dr. Adi is a Pediatri Endorinologist, diaetes speialist and Diretor of the Madison Clini for Pediatri Diaetes at UCSF Benioff Children s Hospital and the UCSF Diaetes Center. Duties: Dr. Adi will serve as lead medial advisor to Tidepool. Compensation:. Dr. Adi will ontinue to e a full-time employee of UCSF. His advisory role with Tidepool is unompensated. Average hours per week worked for Tidepool: 1 Dr. Aaron Neinstein is an adult Endorinologist at UCSF. He is a noted expert in the intersetion etween tehnologial innovations and system improvement in healthare. Duties: Dr. Neinstein will oversee the integration of the Tidepool platform with other linial information systems at UCSF. He will also advise on medial aspets of system development. Compensation:. Dr. Neinstein will ontinue to e a full-time employee of UCSF. His advisory role with Tidepool is unompensated. Average hours per week worked for Tidepool: 1 Dr. Jenise Wong Qualifiations: Dr. Wong is an Assistant Professor of Pediatri Endorinology at UCSF, a pediatri endorinologist at the Madison Clini for Pediatri Diaetes, and a sholar speializing in linial researh in hildhood type 1 diaetes and diaetes tehnology.