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Form } 8868 App ( ation for Extension of Time (' File an (December 2000) Exempt Organization Return Department of the Treasury OMB No. 1545-1709 Internal Revenue service )o, File a separate application for each return, • If you are filing for an Automatic 311111VIonth Extension, complete only Part 1 and check this box . . . . . 91 . . . . . . . . . . . . . . . • If you are filing for an Additional (not automatic) 3-Month Extension, complete only Part 11 (on page 2 of this form) , Note: Do not complete Part 11 unless you have already been granted an automatic 3-month extension on a previously filed Form 8868, Part I Automatic 31111lMonth Extension of Time — Only submit original (no copies needed) Note: Form 990- T corporations requesting an automatic 6-month extension — check this box and complete Part l only . . . . ` ❑ All other corporations (including Form 990-C filers) must use Form 7004 to request an extension of time to nile income lax returns. Partnerships, REM/Cs and trusts must use Form 8.736 to request an extension of time to frle Form 1665, 1066, or 1041. Type or Name of Exempt Organization Employer Identification number print INDIAN RIVER MEMORIAL HOSPITAL , INC . 59 - 2496294 Fite by the Number, street, and room or suite no, If a P.O. box, see instructions, due Ming yourate 1000 36TH STREET Ming your - retur. See City, town or post office, state, and2IP code, For a foreign address, see instructions, instructions. VERO BEACH FL 32960 Check type of return to be filed (file a separate- application for each return) : ❑X Form 990 ❑ Form 990-T (corporation) ❑ Form 4720 - ❑ Form 990-BL ❑ Form 990-T (sec. 401 (a) or 408 (a) trust) ❑ Form 5227 ❑ Form 990-EZ ❑ Form 990-T (trust other than above) ❑ Form 6069 ❑ Form 990-PF ❑ Form 1041 -A ❑ Fora 8870 • If the organization does not have an office or place of business in the United States, check this box . I I I I I I I . . . is If this is for a Group Return, enter the organization's four digit Group Exemption Number (GEN) 0, E]( ) If this is for the whole group, check this box I• El If it is for part of the group, check this box � ❑ and attach a list with the names and EINs of all members the extension will cover. 1 I request an automatic 3-month (6-month , for 990-T corporation) extension of time until - MAY 15 - 120 - 02 to file the exempt organization return for the organization named above. The extension is for the organization's return for. ► ❑ calendar year 20 — or lip. tax❑X tax year beginning - OCTOBER 1 - :.. , 2000 , and ending SEPTEMBER -30 20 01 - 2 If this tax year is for less than 12 months, check reason : ❑ Initial return ❑ Final return ❑ Change in accounting period 3a If this application is for Form 990-13L, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any nonrefundable credits, See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ - $- b If this application is for Form 990-PF or 990-T, enter any refundable credits and estimated tax payments made. Include any prior year overpayment allowed as a credit . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . $ c Balance Due. Subtract line 3b from line 3a. Include your payment with this form , or, if required, deposit with FTD coupon or, if required, by using EFTPS (Electronic Federal Tax Payment System) . See instructions 11 $ Signature and Verification Under penalties of pedury, I declare that 1 have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete, and that I am authorized to prepare this form. Signature )o- h+.vTitle ► Date p 1 For Paperwork Reduction Act Not! e, ee Instruction Form 8868 ( 12-2000) PricewaterhouseCoopers LLP Tampa, Florida 3360211,5147 13 -4008324 ISA STF FED9056F. 1