Form 1024-A - Application For Recognition Of Exemption Page 4

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Form 1024-A (1-2018)

Name:

EIN:

Page

Part VII

Annual Filing Requirements (see instructions)

Yes

Certain organizations aren't required to file an information return. If you are granted tax-exemption, are you

claiming to be excused from filing an information return? If “Yes,” explain in an attachment.

If you fail to file a required information return for three consecutive years, your exempt status will be revoked.

Part VIII

Information Regarding Notification Requirement Under Section 506

Most organizations operating under section 501(c)(4) are required to notify the IRS that they are operating under section 501(c)(4)

within 60 days of formation by filing Form 8976, Notice of Intent to Operate Under Section 501(c)(4). If an organization doesn't submit

a timely notification, a penalty will be assessed. Submission of Form 1024-A doesn't satisfy the requirement to provide notice to the

IRS. See instructions for additional information regarding the notification requirement.

Part IX

User Fee Information and Signature

You must include Form 8718 and the correct user fee payment with this application. If you don't submit the correct user fee, we won't

process the application and we will return it to you. Your check or money order must be made payable to the United States Treasury.

User fees are subject to change. Check our website at and type “User Fee” in the keyword box, or call Customer

Account Services at 877-829-5500 for current information. Also, attach Form 2848, if the application is signed by a person authorized

by power of attorney.

I declare under the penalties of perjury that I am authorized to sign this application on behalf of the above organization and that I have examined this application,

including the accompanying schedules and attachments, and to the best of my knowledge it is true, correct, and complete.

Please

Sign

Here

(Type or print name of signer)

(Signature of Officer, Director, Trustee, or other authorized

(Date)

individual)

(Type or print title or authority of signer)

1024-A

Form

(1-2018)