Form Ss-6042 - Exemption Request - State Of Tennessee
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1
2State of Tennessee
W A R N I N G : F a l s e o r m i s l e a d i n g s t a t e m e n t s
Subject to maximum $5,000 penalty. T.C.A. §48-101-514
EXEMPTION REQUEST
Department of State
Division of Charitable Solicitations
INSTRUCTIONS: (1) Complete Part A; (2) Complete only one section in Part B;
312 Eighth Avenue North
th
(3) Attach all required documents (failure to do so may result in the denial of your
8
Floor, William R. Snodgrass Tower
request); (4) Two authorized officers must sign the form in the presence of a Notary
Nashville, TN 37243
Public; and (5) Return the form to the Division of Charitable Solicitations.
(615) 741-2555
PART A
:
Name of Organization
: __________________________________________________ FEIN:
Physical Address
:
(Street)
(City)
(State)
(Zip)
Mailing Address
(if different):
(Street)
(City)
(State)
(Zip)
Telephone Number: (___)____________ Fax Number: (
)_____________ Email Address:_____________________
If you solicit contributions under any name(s) other than shown above, indicate name(s) below
:
(Name)
(Name)
Have you applied to the IRS for tax exemption? Yes
No
(Attach IRS Letter of Determination or Application)
Mission Statement
:
PART B
:
:
Section 1
ANNUAL GROSS REVENUE FROM THE PUBLIC LESS THAN $30,000
–
Organization has not begun fundraising activities and does not intend to receive more than $30,000 in gross revenue
from the public during a fiscal year. (Attach proposed budget for fiscal year.)
–
Organization did not receive more than $30,000 in gross revenue from the public during its last fiscal year. (Submit
copy of recently filed IRS Form 990 or complete attached “Summary of Financial Activities” form.)
Note:
You must register with the Secretary of State within thirty (30) days if gross contributions from the public during any
fiscal year exceed thirty thousand dollars.
Section 2: RELIGIOUS ORGANIZATIONS
–
Ecclesiastical or Denominational Organizations or Churches
1.
Are you exempt from federal income tax?
Yes
No
2.
Are religious services and activities held on a regular basis?
Yes
No
3.
Are you required to file the IRS Form 990 if revenue exceeds $25,000?
Yes
No
–
Integral Affiliated Organizations
1.
Are you exempt from federal income tax?
Yes
No
2.
Are you affiliated with an IRS §501(c)(3) organization?
Yes
No
If yes, name of organization: __________________________________________
3.
Are your required to file the IRS Form 990 if revenue exceeds $25,000?
Yes
No
(Attach copy of the IRS Determination Letter)
4.
Does more than 50% of your support come from the organization with
which you are affiliated?
Yes
No
–
Organization is soliciting contributions for the construction and maintenance of a house of worship or
clergyman’s residence.
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