Member Application for Multi-Site Organization

Organization Information

Organization Name

Address

City / State / Zip

County

Phone

Website

Organization Status

Nonprofit

Investor-owned

Primary Contact Name

Primary Contact Title

Primary Contact Phone

Primary Contact Email

Primary Billing Contact Name

Primary Billing Contact Title

Primary Billing Contact Phone

Primary Billing Contact Email

Total Number of Employees Employed in Pennsylvania

Full Time Employees

Part Time Employees

PRN Employees

Names, titles and emails of other key corporate level personnel (e.g., CFO, COO, Marketing, Technology, Billing, etc.):

Affiliation (if applicable):

Religious

Fraternal

Government

Hospital

Community

Other...

Provider Affiliate Entities - Provider Name & EIN Number

Please download and complete the Provider Information Form for each provider affiliate community, and upload below or email to membership@leadingagepa.org after you submit your application.

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Membership Dues Calculations

LeadingAge PA and LeadingAge National dues are calculated based on annual Program Service Revenue (PSR)* that is collected by an organization at the site level. There are also Special Program categories that are not assessed dues based on PSR (e.g. Subsidized Housing). Please see the 2021 Membership Dues Formula.

* Program Service Revenue is defined as the revenue an organization receives from aging services activities that are “primarily those that form the basis for an organization’s exemption from tax." It EXCLUDES unrelated items such as interest, realized and unrealized gains or losses, special events/activities, charitable contributions, and other unrelated services.

The PSR should come from IRS Form 990, Part I, Line 9 of the most recently completed fiscal year.

For each provider, please report your PSR and the fiscal year it represents:

As part of your application, please upload below:

proof of 501c status as a nonprofit
verification of the facility’s valid operation license (if applicable)
a copy of the Pennsylvania Sales Tax Exemption Certificate (if applicable)

If your organization does not file a Form 990 with the , provide PSR from one of the following documents using the definition:

most recent Audited Financial Statement
Medicaid Cost Report
Profit and Loss statement
Rental Income (Housing members only)

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As the authorized agent for the organization/agency, I certify the organization’s Board of Directors accepts the standards for membership and is in compliance.

I understand that I am certifying the statement above by checking this box.

Name of Authorizing CEO/Administrator

Title

Date

New code

Please type the code above