Verification Of Filing With The Internal Revenue Service Form

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Charitable Law Section
150 E. Gay St., 23rd Fl.
Columbus, OH 43215
Telephone: (614) 466-3180
Facsimile: (614) 466-9788
VERIFICATION OF FILING WITH THE INTERNAL REVENUE SERVICE
This form is to be completed by 501(c)(3) non-profit organizations, located in Ohio, that file
one of the federal tax forms listed below. NOTE: This form should be filed in lieu of a copy
Do not submit the federal return with this form.
of the federal tax return.
I hereby certify that I am a trustee or officer of
(Name of Organization as filed with the Attorney General's Office)
Charity
Street
Address
City
Zip Code
(Federal Employer Identification Number)
(State Charter Number if applicable)
and that the above named organization completed and/or will complete and file: (check one of the
following)
_____Form 990
_____Form 990-PF
_____Form 990-EZ
required by the Internal Revenue Service for the: (check and complete one of the following)
calendar year 2
, 2
, and ending
tax year beginning
,2
and that such filing occurred on/or will occur on
(Filing Date)
Did the organization request a federal extension of time to file this report? ___Y ___N
If yes, what was/is the extended due date?
(Federal Extended Due Date)
For fee purposes, please indicate the current value of assets, or if filing this form prior to an
extended federal due date, estimate the current value of assets, at year end $
Telephone Number
Name of Trustee/Officer (Please Print)
OFFICE USE ONLY
Signature of Trustee/Officer
FILING FEE PAID
Amount:______________________
Trustee/Officer Title
Date:_______________________
Check #:_____________________
Date
E-mail Address of Charitable Organization
VFIRS/Revised 1/07

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