The Monsanto Fund must determine that a private hospital would be recognized as tax exempt under U.S.concepts before a grant can be made. The term "hospital" includes rehabilitation institutions and outpatient clinics if such organization ’s principal purpose is providing medical care. Please fill in the following questionnaire to the best of your ability to help us determine your eligibility for a grant.

1. State the full name and mailing address of your hospital.





2. List the name and address of the responsible officer or officers of your hospital.






3. Attach a true and correct copy of your hospital’s creating instrument (Articles of Incorporation, Constitution, Articles of Association, Deed of Trust, Indenture, etc.).
   NOTE:If your hospital does not have a creating instrument, its request for a grant from Monsanto Fund will not be considered.



4. Attach a true and correct copy of your hospital's By-Laws, Statutes, or other rules governing its operations.



5. Please state, in narrative form, the activities presently carried on by your hospital, as well as any activities it is contemplated will be carried on in the future. Is the principal purpose or function of your hospital the providing of medical or hospital care or medical education or research? Bear in mind that "medical care" includes the treatment of any physical or mental condition whether such treatment is rendered on an inpatient or outpatient basis. Also,please fill out Exhibit A.
   (NOTE:Public hospitals do not need to complete this document.)










6. What benefits, services, or products does your hospital provide with respect to its charitable function?










7. Are the recipients of any benefits from your hospital required to pay for them?
   NOTE: If the answer is yes, please explain and show how the charges are determined.










8. Does your hospital limit its benefits, services or products to specific classes of individuals?
   NOTE: If the answer to the above is yes, explain in detail how the recipients or beneficiaries are selected.










9. Does or will your hospital engage in activities involving the influencing of legislation or the intervention in any way in political campaigns?
   NOTE: If the answer is yes, please explain in detail.

Exhibit A

Additional Information to be Provided by Hospital

1. (a) How many doctors are on the hospital's courtesy staff?
   
   
   (b) Do such doctors include all the doctors in the community?
   [   ] Yes   [   ] No



2. (a) Does the hospital maintain a full-time emergency room?
   [   ] Yes   [   ] No
   
   (b) What is the hospital ’s policy as to administering emergency services to persons without apparent means to pay?
   
   
   
   
   
   
   
   
   (c)Does the hospital have any arrangements with police, fire,and voluntary ambulance services as to the delivery or admission of emergency cases?
   [   ] Yes   [   ] No
   Please Explain...
   
   
   
   
   
   
   
   
   
   
3. Does or will the hospital provide for a portion of its services and facilities to be used for charity patients?
   
   
   
   Please explain (include data as to the hospital ’s past experience in admitting charity patients and arrangements it may have with municipal or governmental agencies for absorbing the cost of such care).










4. Does or will the hospital carry on a formal program of medical training and research?
   [   ] Yes   [   ] No
   
   If "Yes,"please describe...
   
   
   
   
   
   
   
   
   
5. Does the hospital provide office space to physicians carrying on a medical practice?
   [   ] Yes   [   ] No
   
   If "Yes", attach a list setting forth the name of each physician,the amount of space provided, the annual rent (if any) and the expiration of the current lease.