Free ss-6042.indd - Tennessee

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State of Tennessee

WARNING: False or misleading statements Subject to maximum $5,000 civil penalty. T.C.A. §48-101-514

EXEMPTION 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 Fax (615) 253-5173

INSTRUCTIONS: Complete this form if your organization claims to be exempt from registration because it receives less than $30,000 in gross contributions from the public. The principal officer of the organization must sign the form in the presence of a notary public.
FEIN:

1. Name of Organization: 2. Physical Address:
(Street) (City) (City)

(State) (State)

(Zip) (Zip)

3. Mailing Address (if different): 4. Telephone Number: ( )

(Street)

Fax Number: (

)

Email Address:

5. If you solicit contributions under any name(s) other than shown above, indicate name(s) below: (Name) (Name) 6. A. Legal entity of organization: Corporation Partnership B. When and where was the legal entity organized? Date: Association Other (specify) City: State:

7. If the organization is a corporation, attach the charter or similar document. If the organization is not a corporation, attach a copy of the bylaws. 8. Is the organization recognized by the Internal Revenue Service as tax exempt? Yes (Attach a copy of the determination letter) No 9. Does the organization intend to solicit and receive more than $30,000 in gross contributions from the public during an accounting year? Yes No 10.Has the organization received more than $30,000 in gross contributions from the public during any accounting year? Yes No (Submit a copy of the IRS Form 990 from the most recently completed accounting year, or, if a 990 is not required to be filed with the IRS, complete the attached "Summary of Financial Activities" form with financial information from the organization's most recently completed accounting year.) Note: You must register with the Secretary of State within thirty (30) days if gross contributions from the public during any accounting year exceed thirty thousand dollars ($30,000). Signature This document must be signed by an authorized officer. I certify that the statements in this registration statement and all supplemental forms, documents, and continuation sheets are true and correct to the best of my knowledge and belief.
Signature of Owner / Authorized Officer

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Title Date
SS-6042 (Rev. 04/09) RDA 1742