Form 8868 - Application For Extension Of Time To File An Exempt Organization Return Form Page 2

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Form 8868 (Rev. 4-2009)

Page

If you are filing for an Additional (Not Automatic) 3-Month Extension, complete only Part II and check this box

Note. Only complete Part II if you have already been granted an automatic 3-month extension on a previously filed Form 8868.

If you are filing for an Automatic 3-Month Extension, complete only Part I (on page 1).

Part II

Additional (Not Automatic) 3-Month Extension of Time. Only file the original (no copies needed).

Name of Exempt Organization

Employer identification number

Type or

Number, street, and room or suite no. If a P.O. box, see instructions.

For IRS use only

File by the

extended

due date for

filing the

City, town or post office, state, and ZIP code. For a foreign address, see instructions.

return. See

instructions.

Check type of return to be filed (File a separate application for each return):

Form 990

Form 990-PF

Form 1041-A

Form 6069

Form 990-BL

Form 990-T (sec. 401(a) or 408(a) trust)

Form 4720

Form 8870

Form 990-EZ

Form 990-T (trust other than above)

Form 5227

STOP! Do not complete Part II if you were not already granted an automatic 3-month extension on a previously filed Form 8868.

The books are in the care of

(

)

(

)

Telephone No.

FAX No.

If the organization does not have an office or place of business in the United States, check this box

If this is for a Group Return, enter the organization’s four digit Group Exemption Number (GEN)

. If this is

for the whole group, check this box . . . . . .

. If it is for part of the group, check this box. . . . . .

and attach a

list with the names and EINs of all members the extension is for.

I request an additional 3-month extension of time until

, 20

For calendar year

, or other tax year beginning

, 20

, and ending

, 20

If this tax year is for less than 12 months, check reason:

Initial return

Final return

Change in accounting period

State in detail why you need the extension

8a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax,

less any nonrefundable credits. See instructions.

b If this application is for Form 990-PF, 990-T, 4720, or 6069, enter any refundable credits and

estimated tax payments made. Include any prior year overpayment allowed as a credit and any

amount paid previously with Form 8868.

c Balance Due. Subtract line 8b from line 8a. Include your payment with this form, or, if required, deposit

with FTD coupon or, if required, by using EFTPS (Electronic Federal Tax Payment System). See instructions.

Signature and Verification

Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief,

it is true, correct, and complete, and that I am authorized to prepare this form.

Signature

Title

Date

8868

Form

(Rev. 4-2009)