Member Application for Multi-Site Organization 

Organization Information

Organization Status

Affiliation (if applicable):

Please download and complete the Provider Information Form for each provider affiliate community, and upload below or email to 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.

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.