Form Fr-164 - Application For Exemption
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3APPLICATION FOR EXEMPTION, FR-164
GOVERNMENT OF THE DISTRICT OF COLUMBIA
(Check Appropriate Boxes)
OFFICE OF TAX AND REVENUE
P.O. BOX 556
W ASHINGTON, DC 20044-0556
INCOME AND FRANCHISE TA X
FAX # (202) 442-6882
SALES AND USE TAX (SEMIPUBLIC INSTITUTION ONLY)
PERSONAL PROPERTY TAX (SEMIPUBLIC INSTITUTION ONLY)
1 . Full name of organization
F E I N #
2 . Complete address (number, city/town and Postal Zip Code of the organization: P.O. Box is not acceptable.) including Website
3 . Federal Exemption St a t u s :
Exemption recognized
Date ________________________ Internal Revenue Code Section_________________________________
Application filed (if not recognized) Date ________________________
Internal Revenue Code Section________________________
4 . Form of Organization:
Corporation
Date of incorporation___________________St ate_______________________________
Other-Describe__________________________________________________________________________________________________
5 . Purpose of Organization:
Religious
Library
Other: Explain: _____________________________________________________
Charitable
Educational
S c i e n t i f i c
Hospita l
6 . Principal Sources of Income:
Donations
Assessments
I n t e r e s t
Other: Explain______________________________
Grants
Initiation Fees
Dividends
Dues
Rents
Business Operations
7 . End of Annual Accounting Period:_______________________________________________________________________________________
8 . Date activities began in the District:_______________________________________________________________________________________
9a. Physical Location(s) of Personal Property in the District:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
9 b . Type of Personal Property Owned by Organization:
(Also list total cost of property owned and located in the District)
Person Authorized to Discuss Application for Exemption:
Name:______________________________________
Title:______________________________
Telephone:_______________________________
Address:_____________________________________________________________________FAX:__________________Email:________________
SIGNATURE AND VERIFICATION
Under the penalties provided by law, I declare that I have examined this application, including accompanying statements, and to the best of my knowledge and belief it is
true, correct and complete.
Signature of Off i c e r
Ti t l e
Date
FR-164 (Rev. 12/2007)
PLEASE COMPLETE REVERSE SIDE
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