Form Ss-6074 - Extension Request - Tennessee Department Of State - 2009

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State of Tennessee
W AR 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 civil penalty. T.C.A. §48-101-514
EXTENSION REQUEST
Department of State
INSTRUCTIONS: Pursuant to T.C.A. § 48-101-506(e), for good cause
Division of Charitable Solicitations & Gaming
shown, the secretary may
the time for filing a renewal application for a period
William R. Snodgrass Tennessee Tower
extend
th
not to exceed ninety (90) days during which time the previous registration remains
312 Rosa L. Parks Avenue, 8
Floor
in effect. Please complete the form stating the reason for the extension request.
Nashville, TN 37243
(615) 741-2555
(615) 253-5173 fax
Name of Organization: _________________________________________________
CO ID: ____________
Contact Name: _____________________________________________
FEIN: ________________________
Mailing Address: ____________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Telephone Number: (___)__________ Fax Number: (
)___________ Email Address:__________________
______________________________________________________________
Reason for extension request: _________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
 Supporting documentation attached (e.g. IRS Form 8868 - exempt organization extension to file).
______________________________________________________________
SIGNATURE
I certify that the information furnished in this Request for Extension (and all continuation sheets) is true
and correct to the best of my knowledge.
__________________________________________________
___________________
Signature of Principal Officer or Authorized Representative
Date
__________________________________________________
Print Name
__________________________________________________
Title
SS-6074
(6/19/09)
RDA Pending

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