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

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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)
Inspection
Information about Form 5578 and its instructions is at
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
1b Employer identification number
Name of organization that operates, supervises, and/or controls school(s).
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
3b Employer identification number,
Name of school. (If more than one school, write “See Attached,” and attach a list of the names, complete addresses,
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

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