Ps Form 3624 - About Usps printable pdf download

Application to Mail at

Nonprofit Standard Mail Prices

Application Number:

Section A - Application (Please read section B on page 2 before completion.)

Part 1 (For completion by applicant)

All information entered below must be legible so that our records will

The applicant named in item 7 must be the individual submitting the

show the correct information about your organization.

application for the organization and must be a responsible official of the

organization. Printers and mailing agents may not sign for the organization.

The complete name of the organization must be shown in item 1.

The name shown must agree with the name that appears on all

No additional organization categories may be added in item 9. To be

documents submitted to support this application.

eligible for the Nonprofit Standard Mail prices, the organization must qualify

as one of the types listed.

A complete address representing a physical location for the

organization must be shown in item 2. If you receive mail through a

The applicant must sign the application in item 15.

Post Office™ box, show your street address first and use alternate

The application must be submitted to the Post Office in item 14 and on the

address for the box.

date shown in item 17.

No application fee is required. (All information must be complete and typewritten or printed legibly

1. Complete Name of Organization (If voting registration official, include title)

2. Street Address of Organization (Include apartment or suite number)

3. City, State, ZIP+4

Code

5. Alternate City, State, ZIP+4

Code

4. Alternate Mailing Address

6. Telephone (Include area code)

7. Name of Applicant (Must represent applying organization)

8. Email Address

9. Type of Organization (Check only one)

(09) Qualified political committee

(01) Religious

(03) Scientific

(05) Agricultural

(07) Veterans

(Go to item 12)

(10) Voting registration official

(02) Educational

(04) Philanthropic

(06) Labor

(08) Fraternal

(Go to item 12)

Not all nonprofit organizations are eligible for the Nonprofit Standard Mail prices. Domestic Mail Manual® 703.1 lists certain organizations (such as

business leagues, chambers of commerce, civic improvement associations, social and hobby clubs, governmental bodies, and others) that, although

nonprofit, do not qualify for the Nonprofit Standard Mail prices.

10. Is this a for-profit organization or does any of the net income

12. Has this organization previously mailed at the Nonprofit

Yes

inure to the benefit of any private stockholder or individual?

Standard Mail prices? (If `Yes,’ list the Post Office locations

where mailings were most recently deposited at these prices

and provide the nonprofit authorization number, if known.)

11. Is this organization exempt from federal income tax? (If

Yes

‘Yes,’ attach a copy of the exemption issued by the Internal

Revenue Service (IRS) that shows the section of the IRS

code under which the organization is exempt. Required if

13. Has your organization had Nonprofit Standard Mail privileges

exempt. Do not submit State tax exemption information.)

Yes

denied or revoked? (If `Yes,’ list the Post Office (city and

Has the IRS denied or revoked the organization’s federal tax

state) where the application was denied or authorization was

exempt status? (If `Yes,’ attach a copy of the IRS ruling

revoked and provide the nonprofit authorization number, if

to this PS Form 3624.)

known.)

From your IRS exemption letter, check off the box corresponding

to the section under which the organization is exempt:

501(c)(3)

501(c)(5)

14. Post Office (not a station or branch) where authorization

501(c)(8)

501(c)(19)

requested and bulk mailings will be made (City, state, ZIP

Code™).

Other 501(c) (

) (See statement in item 9 above)

I certify that the statements made by me are true and complete. I understand that anyone who furnishes false or misleading information on this form or who

omits material information requested on the form may be subject to criminal sanctions (including fines and imprisonment) and/or civil sanctions (including multiple

damages and civil penalties). I further understand that, if this application is approved, a postage refund for the difference between the regular Standard Mail and

Nonprofit Standard Mail prices may be made for only mailings entered at regular Standard Mail prices at the Post Office identified above while this application is pending,

provided that the conditions set forth in Domestic Mail Manual 703.1 and 703.1.9 are met.

15. Signature of Applicant

16. Title

17. Date

Part 2 (For completion by postmaster at originating office when application filed)

1. Signature of Postmaster (Or designated representative)

2. Date Application Filed With Post Office (Round stamp)

3624,

PS Form

April 2012 (Page 1 of 3) PSN 7530-02-000-9014

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