Free Extension Request - Tennessee

State of Tennessee

W AR N I N G : F a l s e o r m i s l e a d i n g s t a t e m e n t s Subject to maximum $5,000 civil penalty. T.C.A. §48-101-514

EXTENSION REQUEST
Department of State
Division of Charitable Solicitations & Gaming William R. Snodgrass Tennessee Tower 312 Rosa L. Parks Avenue, 8th Floor Nashville, TN 37243 (615) 741-2555 (615) 253-5173 fax

INSTRUCTIONS: Pursuant to T.C.A. § 48-101-506(e), for good cause shown, the secretary may extend the time for filing a renewal application for a period not to exceed ninety (90) days during which time the previous registration remains in effect. Please complete the form stating the reason for the extension request.

Name of Organization: _________________________________________________ Contact Name: _____________________________________________
(Street) (City)

CO ID: ____________

FEIN: ________________________
(State) (Zip)

Mailing Address: ____________________________________________________________________________ Telephone Number: (___)__________ Fax Number: ( )___________ Email Address:__________________

______________________________________________________________
Reason for extension request: _________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Supporting documentation attached (e.g. IRS Form 8868 - exempt organization extension to file).

______________________________________________________________
SIGNATURE

I certify that the information furnished in this Request for Extension (and all continuation sheets) is true and correct to the best of my knowledge.
__________________________________________________ Signature of Principal Officer or Authorized Representative __________________________________________________ Print Name __________________________________________________ Title ___________________ Date

SS-6074

(6/19/09)

RDA Pending