California Form 3500a - Submission Of Exemption Request

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CALIFORNIA FORM

Submission of Exemption Request

3500A

Exemption Based on Internal Revenue Code (IRC) Section 501(c)(3) Federal Determination Letter

Enclose a copy of the Federal Determination Letter.

California Corporation number/ California Secretary of State file number

FEIN

Name of organization as shown in the creating document

Address (suite, room, or PMB no.)

Daytime telephone number

(

)

City

State

ZIP Code

Name of representative to contact regarding additional requirements or information

Daytime telephone number

(

)

Representative’s mailing address (suite, room, or PMB no.)

City

State

ZIP Code

Part I — Purpose and Activity

Check the organization’s primary purpose and activity as allowed in the federal determination letter:

Charitable

Educational

Religious

Testing for public safety

School

Literary

Hospital

Medical center

Credit counseling organization

Qualified sports organization

Health care center

Scientific

Church

Prevent cruelty to children or animals

Part II — Entity Information

Entity type (check applicable box):

Corporation

Association

Trust

Foreign corporation (State of incorporation) _______________

Does the IRS consider the organization a private foundation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Yes

When did the organization establish, incorporate, organize, or conduct business in California? . . . . . . . . . . . . . . . . . . . . . . . 4

____ / ____ / ____

yyyy

Provide gross receipts for the current year and the three immediately preceding taxable years in existence . Gross receipts

are defined as the total amounts the organization received from all sources during its annual account period without

subtracting any costs or expenses . If the organization has been in existence for less than one year, provide the projected

amount of gross receipts for the entire year .

Current Year or Projected

Gross Receipts for the three immediately preceding taxable years:

Gross Receipts

From:

To:

Has the IRS ever suspended, revoked, or audited the organization? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Yes

If “Yes,” explain _______________________________________________________________________________________________________

Part III — Group Exemption. See instructions .

Is the organization applying for a group exemption? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Yes

If “Yes,” attach the federal group determination letter and a list of all California subordinates . Include each subordinate’s name,

corporation number, FEIN, and address .

Mail form FTB 3500A and a copy of the federal determination letter to:

EXEMPT ORGANIZATIONS UNIT, MS F120, FRANCHISE TAX BOARD, PO BOX 1286, RANCHO CORDOVA CA 95741-1286 .

Under penalties of perjury, I declare I have examined this submission for exemption based on the IRC Section 501(c)(3) federal

determination letter, and to the best of my knowledge and belief, it is true, correct, and complete.

_________________________

________________________________________________________

______________________________

DATE

SIGNATURE OF OFFICER OR REPRESENTATIVE