Form 8453-Eo - Exempt Organization Declaration And Signature For Electronic Filing - 2014

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Exempt Organization Declaration and Signature for

8453-EO

OMB No. 1545-1879

Electronic Filing

Form

2014

For calendar year 2014, or tax year beginning

, 2014, and ending

, 20

For use with Forms 990, 990-EZ, 990-PF, 1120-POL, and 8868

Department of the Treasury

Internal Revenue Service

Employer identification number

Name of exempt organization

Type of Return and Return Information (Whole Dollars Only)

Part I

Check the box for the type of return being filed with Form 8453-EO and enter the applicable amount, if any, from the return. If you

check the box on line 1a, 2a, 3a, 4a, or 5a below and the amount on that line of the return being filed with this form was blank, then

leave line 1b, 2b, 3b, 4b, or 5b, whichever is applicable, blank (do not enter -0-). If you entered -0- on the return, then enter -0- on the

applicable line below. Do not complete more than one line in Part I.

Form 990 check here

b Total revenue, if any (Form 990, Part VIII, column (A), line 12) .

▶

Form 990-EZ check here

b Total revenue, if any (Form 990-EZ, line 9) .

▶

Form 1120-POL check here

b Total tax (Form 1120-POL, line 22) .

▶

Form 990-PF check here

b Tax based on investment income (Form 990-PF, Part VI, line 5)

▶

Form 8868 check here

b Balance due (Form 8868, Part I, line 3c or Part II, line 8c)

▶

Declaration of Officer

Part II

I authorize the U.S. Treasury and its designated Financial Agent to initiate an Automated Clearing House (ACH) electronic funds

withdrawal (direct debit) entry to the financial institution account indicated in the tax preparation software for payment of the

organization’s federal taxes owed on this return, and the financial institution to debit the entry to this account. To revoke a payment,

I must contact the U.S. Treasury Financial Agent at 1-888-353-4537 no later than 2 business days prior to the payment (settlement)

date. I also authorize the financial institutions involved in the processing of the electronic payment of taxes to receive confidential

information necessary to answer inquiries and resolve issues related to the payment.

If a copy of this return is being filed with a state agency(ies) regulating charities as part of the IRS Fed/State program, I certify that I

executed the electronic disclosure consent contained within this return allowing disclosure by the IRS of this Form 990/990-EZ/990-

PF (as specifically identified in Part I above) to the selected state agency(ies).

Under penalties of perjury, I declare that I am an officer of the above named organization and that I have examined a copy of the

organization’s 2014 electronic return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true,

correct, and complete. I further declare that the amount in Part I above is the amount shown on the copy of the organization’s electronic

return. I consent to allow my intermediate service provider, transmitter, or electronic return originator (ERO) to send the organization’s return

to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection of the transmission, (b) the reason for any

delay in processing the return or refund, and (c) the date of any refund.

Sign

Here

Signature of officer

Date

Title

Declaration of Electronic Return Originator (ERO) and Paid Preparer (see instructions)

Part III

I declare that I have reviewed the above organization’s return and that the entries on Form 8453-EO are complete and correct to the best of

my knowledge. If I am only a collector, I am not responsible for reviewing the return and only declare that this form accurately reflects the data

on the return. The organization officer will have signed this form before I submit the return. I will give the officer a copy of all forms and

information to be filed with the IRS, and have followed all other requirements in Pub. 4163, Modernized e-File (MeF) Information for Authorized

IRS e-file Providers for Business Returns. If I am also the Paid Preparer, under penalties of perjury I declare that I have examined the above

organization’s return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and

complete. This Paid Preparer declaration is based on all information of which I have any knowledge.

Date

Check if

ERO’s SSN or PTIN

Check if

ERO’s

also paid

self-

ERO’s

signature

preparer

employed

Use

Firm’s name (or

EIN

yours if self-employed),

Only

address, and ZIP code

Phone no.

Under penalties of perjury, I declare that I have examined the above return and accompanying schedules and statements, and to the best of my knowledge

and belief, they are true, correct, and complete. Declaration of preparer is based on all information of which the preparer has any knowledge.

Print/Type preparer’s name

Preparer’s signature

Date

PTIN

Paid

Check

self- employed

Preparer

Firm’s name

Firm's EIN

Use Only