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CT-247

New York State Department of Taxation and Finance

Application for Exemption from Corporation Franchise Taxes

(6/99)

By a Not-for-Profit Organization

Legal name of corporation

Employer identification number

For office use only

Mailing name at location below (if different from legal name) and address

c/o

Number and street or PO Box

City

State

ZIP code

Principal business activity

Date tax exemption claimed from

For audit use only

Form of organization

Business/officer telephone number

(

)

Corporation

Association

Trust

Other

Date of formation

State or country of incorporation

Taxable

Exempt

Indicate exact name of the law under which the entity was formed ( general corporation, not-for-profit, membership, etc.). Cite statutory provisions.

Federal return filed on Form:

990

990T

1120

Other:

1 Is the entity organized and operated as a not-for-profit organization? ..............................................................................

Yes

2 Is the entity authorized to issue capital stock? If Yes, check the appropriate box below ................................................

Yes

Title holding company

Collective investment

Other:_________________________________________________

List shareholders: _____________________________________________________________________________________________

3 Does any part of the net earnings of the organization benefit any officer, director, or member? ......................................

Yes

4 Is the entity exempt from federal income tax? ...................................................................................................................

Yes

If Yes, indicate date of exemption: ______________________ Submit a copy of the federal exemption letter when filing this form.

If No, indicate reason why exemption disallowed:

___________________________________________________________________

5 Is the entity engaged in an unrelated business activity at a location in New York State? .................................................

Yes

6 Is the entity operating as a trust under section 401(a) and exempt from federal income tax under section 501(a)

of the Internal Revenue Code? ......................................................................................................................................

Yes

7 List location and type of activity for each office and other places of business

(attach separate sheet if necessary).

Location

Nature of activity

8 List officers, employees, agents and representatives in New York State and briefly describe their duties

(attach separate sheet if necessary).

Name

Title

Duties

9 List type and use of real property owned in New York State (

attach separate sheet if necessary ).