Short Form Pc, Schedule A-2, Certification By Organization - 2009

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PC
Check all items attached (if
hort
orm
applicable):
Report for the Fiscal Period:
to
□
Articles of Organization or
Agreement of Association or
Attorney General’s Account #:
Instrument of trust or written
statement of purpose
Federal ID #:
□
Copy of the IRS letter
designating the 501(c)(3) status
To be filed only by organizations that wish to solicit funds prior to completion of
□
List of current officer/director
their first fiscal year.
names and addresses
□
By-laws
When did the organization first engage in charitable work in Massachusetts?
Has the organization applied for or been granted IRS tax exempt status?
Yes
No
If yes, date of application OR date of determination letter:
IRS Exemption under 501(c):
If exempt under 501(c), are contributions to the organization tax
deductible as charitable contributions?
Yes
No
o
D
rganization
ata
Name:
Mailing Address:
City:
State:
Zip:
Phone:
(
)
Fax:
(
)
Email:
Website:
In the table below, please enter the appropriate codes from the corresponding tables found in the instructions.
Enter up to 2 codes from Table 3 for your organization’s main purpose(s)
Category
Code
Category
Code
County (Table 1)
Organization Purpose Code 1
Type of Organization (Table 2)
Organization Purpose Code 2
Office Use Only
Payment Received
Short Form PC
Page 1 of 4
Rev. 05/2009

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