Form 5578 - Annual Certification Of Racial Nondiscrimination For A Private School Exempt From Federal Income Tax

5578

Annual Certification of Racial Nondiscrimination

OMB No. 1545-0213

Form

for a Private School Exempt From Federal Income Tax

Open to Public

(Rev. August 2013)

Information about Form 5578 and its instructions is at

Inspection

Department of the Treasury

(For use by organizations that do not file Form 990 or Form 990-EZ)

For IRS Use Only

Internal Revenue Service

For the period beginning

,

and ending

,

1a

Name of organization that operates, supervises, and/or controls school(s).

1b Employer identification number

Address (number and street or P.O. box no., if mail is not delivered to street address)

Room/suite

City or town, state, and ZIP + 4 (If foreign address, list city or town, state or province, and country. Include postal code.)

2a

Name of central organization holding group exemption letter covering the school(s). (If same as 1a above, write

2b Employer identification number

“Same” and complete 2c.) If the organization in 1a holds an individual exemption letter, write “Not Applicable.”

Address (number and street or P.O. box no., if mail is not delivered to street address)

Room/suite

2c Group exemption number (see

instructions under Definitions)

City or town, state, and ZIP + 4 (If foreign address, list city or town, state or province, and country. Include postal code.)

3a

Name of school. (If more than one school, write “See Attached,” and attach a list of the names, complete addresses,

3b Employer identification number,

including postal codes, and employer identification numbers of the schools.) If same as 1a, write “Same.”

if any

Address (number and street or P.O. box no., if mail is not delivered to street address)

Room/suite

City or town, state, and ZIP + 4 (If foreign address, list city or town, state or province, and country. Include postal code.)

Under penalties of perjury, I hereby certify that I am authorized to take official action on behalf of the above school(s) and that to the best of my knowledge and belief the

school(s) has (have) satisfied the applicable requirements of sections 4.01 through 4.05 of Rev. Proc. 75-50, 1975-2 C.B. 587, for the period covered by this certification.

(Signature)

(Date)

(Type or print name and title.)

5578

For Paperwork Reduction Act Notice, see instructions.

Form

(Rev. 8-2013)

Cat. No. 42658A