Free State of South Carolina - South Carolina

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State of South Carolina Office of the Secretary of State Division of Public Charities Post Office Box 11350 Columbia, SC 29211 www.scsos.com Telephone: (803) 734-1790 Fax: (803) 734-1604 [email protected]

APPLICATION FOR EXEMPTION FROM REGISTRATION
Check one: [ ] Initial Registration [ ] Renewal Charity Public ID: _______________________________ Organization's Website: ____________________________

Employer's Identification Number: __ __ -- __ __ __ __ __ __ __

Organization's Legal Name _________________________________________________________________________________ Doing Business As (DBA) Names ___________________________________________________________________________ Former Names used by the Charity ___________________________________________________________________________ Demographic Details Current Fiscal Year End Date (Month/Day/Year):_________________________ Basis for exemption according to the Solicitation of Charitable Funds Act (S.C. Code of Laws §33-56-10 et seq.), check ONE of the following: _____ (1) Educational Institution (Schools, colleges, universities, and the foundations of South Carolina colleges and universities) _____ (2) Solicitation for the relief of a specified individual _____ (3) Organizations which do not intend to solicit in excess of $20,000 in a calendar year and have a letter of tax exemption from the IRS, if all of their functions including fundraising activities are conducted by persons who are compensated no more than $500 annually for their services. (Please attach IRS tax letter.) _____ (4) Organization which solicits exclusively from within its own membership, including utility cooperatives _____ (5) Veterans organization which has a congressional charter _____ (6) The State, its political subdivisions, and any agencies or departments thereof which are subject to the disclosure provisions of the Freedom of Information Act _____ (7) Organizations which do not intend to solicit more than $7,500 in a calendar year, regardless of whether or not the solicitation is conducted by professionals Charity Physical Address Organization's Street Address _______________________________________________________________________________ City ________________________________________________________________State ________ Zip ___________________ Charity Contact Information Contact Person's Name __________________________________________ Title _____________________________________ Contact Person's Mailing Address ____________________________________________________________________________ City ________________________________________________________________State ________ Zip ___________________ Telephone (Daytime) (______)________________________________ Fax (_______) _________________________________ Contact Person's E-mail ___________________________________________________________________________________ Charity CEO CEO's Name: _____________________________________________ Telephone Number: (______)______________________ CEO's Mailing Address: ___________________________________________________________________________________ City ________________________________________________________________State ________ Zip ___________________
Exemption Form (Revised May 2009) Page 1 of 2

State of South Carolina Office of the Secretary of State Division of Public Charities

Post Office Box 11350 Columbia, SC 29211 www.scsos.com

Telephone: (803) 734-1790 Fax: (803) 734-1604 [email protected]

Charity CFO CFO's Name: _____________________________________________ Telephone Number: (______)______________________ CFO's Mailing Address: ___________________________________________________________________________________ City ________________________________________________________________State ________ Zip ___________________ Charity Category and Purpose
Complete either Section 1 or Section 2 below which describes both the charity's category and the purpose of the charity's solicited donations. Section 1: Enter up to three NTEE (National Taxonomy of Exempt Entities) Codes here: ____ ____ ____ ____ , ____ ____ ____ ____ , ____ ____ ____ ____ Section 2: Check up to three boxes below that best describe your organization:
A. Arts, Culture, Humanities (inc. historical) B. Educational Institutions (inc. literacy) C. Environment, Beautification (inc. gardening, outdoor education) D. Animal-Related (inc. wildlife sanctuaries) E. Health-General, Rehabilitative (inc. nursing, family planning) F. Mental Health, Crisis Intervention (inc. alcoholism, services for rape and abuse victims) G. Disease, Disorders, Medical Disciplines H. Medical Research I. Crime, Legal-Related (inc. prevention of abuse, delinquency) J. Employment, Job-Related (inc. voc. rehabilitation, unions) K. Agriculture, Food, Nutrition (inc. livestock breeding) L. Housing, Shelter (inc. senior citizen housing) M. Public Safety, Disaster Preparedness and Relief (inc. rescue squads, auto safety) N. Recreation, Sports, Leisure, Athletics (inc. social clubs, Special Olympics) O. Youth Development P. Human Services (inc. thrift stores, YMCAs and YWCAs, hearing- or sight-impaired orgs.) Q. International, Foreign Affairs, National Security (inc. cultural exchange) R. Civil Rights, Social Action, Advocacy (inc. right to life and right to die, reproductive rights) S. Community Improvement, Capacity Building (inc. neighborhood associations, service clubs, bus. development) T. Philanthropy, Volunteerism, Grant-making (inc. foundations) U. Science and Technology Research Institutes (inc. computer science, engineering) V. Social Sciences Institutes (inc. institutes for studies on population, minorities and economics) W. Public Affairs, Society Benefit (inc. citizen participation, consumer protection, veterans' orgs., leadership development) X. Religion, Spiritual Development (inc. religious broadcasters and interfaith coalitions) Y. Mutual / Membership Benefit (inc. fraternal organizations, cemeteries) Z. Unknown, Other Please Specify: ___________________________

CERTIFICATION
I certify that the information furnished in this application and all attached supplementary information is true and correct to the best of my knowledge, information and belief. I understand the giving of false or incorrect information may constitute a misdemeanor carrying a penalty upon conviction, for a first offense of not more than two thousand dollars or imprisonment for not more than one year, or both. A second, or subsequent offense is a felony and upon conviction must be fined not more than five thousand dollars or imprisoned not more than five years, or both.

Chief Executive Officer:

Chief Financial Officer:

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Date

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Exemption Form (Revised May 2009)

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