Exemption Request Form - State Of Tennessee

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State of Tennessee
WARNING: False or misleading st atement s
Subject to maximum $5,000 civil penalty. T.C.A. §48-101-514
EXEMPTION REQUEST
Department of State
INSTRUCTIONS: Complete this form if your organization claims
Division of Charitable Solicitations & Gaming
to be exempt from registration because it receives less than
William R. Snodgrass Tennessee Tower
$30,000 in gross contributions from the public. The principal
th
312 Eighth Avenue North, 8
Floor
officer of the organization must sign the form in the presence of a
Nashville, TN 37243
notary public.
(615) 741-2555
fax (615) 253-5173
_______________________________________________________________________
1. Name of Organization
:
FEIN:
2. Physical Address
:
(Street)
(City)
(State)
(Zip)
3. Mailing Address
(if different):
(Street)
(City)
(State)
(Zip)
4. Telephone Number: (__)
Fax Number: (
)
Email Address:_________________
5. If you solicit contributions under any name(s) other than shown above, indicate name(s) below
:
(Name)
(Name)
6. A. Legal entity of organization:
Corporation
Partnership
Association
Other (specify) ___________
B. When and where was the legal entity organized? Date: _________ City: ________________ State: _____
7. Attach a copy of your charter, bylaws, or other similar governing document.
8. Have you applied to the IRS for tax exemption? Yes
No
)
(Attach IRS Letter of Determination or Application
Mission Statement
:
_______________________________________________________________________________________________
9. Does the organization intend to solicit and receive more than $30,000 in gross contributions from the public
during a fiscal year? Yes
No
10. Has the organization received more than $30,000 in gross contributions from the public during any fiscal
year?
Yes
No
(Submit copy of recently filed IRS Form 990 or complete the attached “Summary of Financial Activities” form
with financial information from the organizations most recently completed fiscal year)
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.
SIGNATURE
I certify that the information furnished in this Request for Exemption (and all continuation sheets) is true
and correct to the best of my knowledge.
Notary Seal
__________________________________________________
Sworn to and subscribed before me at:
Signature of Principal Officer
Date
_________________________________________
__________________________________________________
County / State
Print Name
This, the _______ day of _______________, 20 __.
__________________________________________________
Title
_________________________________________
Signature of Notary Public
SS-6042 (Rev 3/6/08)
RDA 1742

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