Form Ss-6042 - Annual Request For 30,000 Dollars And Under Exemption - 2016
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2Annual Request for $30,000 and Under Exemption
Division of Charitable Solicitations,
For Office Use Only
Fantasy Sports, and Gaming
Department of State
State of Tennessee
312 Rosa L. Parks Avenue, 8th Floor
Nashville, Tennessee 37243
Tre Hargett
Phone: 615-741-2555
Secretary of State
_________
Fax: 615-253-5173
sos.tn.gov/charitable
WARNING: False or misleading statements subject to maximum $5,000 civil penalty. T.C.A. § 48-101-514
Instructions: Complete this form if your organization claims to be exempt from registration because it
receives less than $30,000 in gross contributions from the public. The principal officer of the organization
must sign the form. This form must be submitted annually.
1. Name of Organization:
FEIN:
2. Physical Address:
City:
State:
Zip Code:
County:
3. Mailing Address (if different):
City:
State:
Zip Code:
County:
4. Phone: (
)
Fax: (
)
5. Email:
Website:
6. If you solicit contributions or operate under any name(s) other than shown above, indicate names(s)
below:
Name(s):
7. Legal entity of organization:
A. Corporation Partnership Association Other (specify)
B. When and where was the legal entity organized?
Date:
City:
State:
County:
C. What are the beginning and ending dates of the organization’s accounting period?
Beginning:
Ending:
(mm/dd)
8. If the organization is a corporation, attach the charter or similar document. If the organization is not
a corporation, attach a copy of the bylaws.
9. Is the organization recognized by the Internal Revenue Service as tax exempt?
Yes No (If yes, attach a copy of the determination letter)
SS-6042 (Revised 12/16), RDA 2994
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