Fillable Printable 2016 Form 3500A Submission Of Exemption Request
Fillable Printable 2016 Form 3500A Submission Of Exemption Request
2016 Form 3500A Submission Of Exemption Request
FTB 3500A 2017 Side 1
Submission of Exemption Request
CALIFORNIA FORM
3500A
Exemption Based on Internal Revenue Code (IRC) Sections 501(c)(3), 501(c)(4), 501(c)(5),
501(c)(6), 501(c)(7), or 501(c)(19), Federal Determination Letter
Enclose a copy of the Federal Determination Letter.
Organization Information
California corporation number/California Secretary of State file number FEIN
Name of organization as shown in the creating document
Street address (suite, room, or PMB no.) Telephone
( )
City State ZIP code
Representative Information
Part I — Entity Information
Name of representative to contact regarding additional requirements or information Telephone
( )
Representative’s mailing address (suite, room, or PMB no.)
City State ZIP code
1 Entity type (check applicable box): m Corporation m Association m Trust m Foreign corporation (State of incorporation) _______________
2 Does the IRS consider the organization a private foundation? ................................................. 2 m Yes m No
3
When did the organization establish, incorporate, organize, or conduct business in California? ....................... 3 ____ / ____ / ____
4
Provide gross receipts for the current year and the three immediately preceding taxable years in existence. Gross receipts
are defined as the total amounts the organization received from all sources during its annual account period without
subtracting any costs or expenses. If the organization has been in existence for less than one year, provide the projected
amount of gross receipts for the entire year. List the account period beginning to the account period ending. Example: mm/dd/yyyy
Current Year or Projected
Gross Receipts
Gross Receipts for the three immediately preceding taxable years:
From: From: From: From:
To: To: To: To:
5 Has the IRS ever suspended, revoked, or audited the organization? ............................................ 5 m Yes m No
If “Yes,” explain
mm dd yyyy
Part II — Group Exemption. See instructions.
6 Is the organization applying for a group exemption? ........................................................ 6 m Yes m No
If “Yes,” attach the federal group determination letter and a list of all California subordinates. Include each subordinate’s name,
corporation number, Federal employer identification number (FEIN), and address.
_________________________ ________________________________________________________ ______________________________
DATE SIGNATURE OF OFFICER OR REPRESENTATIVE TITLE
8091173
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Mail form FTB 3500A and a copy of the federal determination letter to:
EXEMPT ORGANIZATIONS UNIT, MS F120, FRANCHISE TAX BOARD, PO BOX 1286, RANCHO CORDOVA
CA 95741-1286.
Under penalties of perjury, I declare I have examined this submission for exemption based on the IRC Sections 501(c)(3), 501(c)(4), 501(c)(5),
501(c)(6), 501(c)(7), or 501(c)(19), federal determination letter, and to the best of my knowledge and belief, it is true, correct, and complete.
FTB 3500A 2017 Side 2
Part III — Purpose and Activity
1 Exemption based on IRC 501(c)(3) Federal Determination Letter
Check the organization’s primary purpose and activity:
m Charitable m Educational m Literary m Prevent cruelty to animals m Prevent cruelty to children
m Testing for public safety m Religious m Scientific m Church m School
m Hospital m Health care center m Qualified sports organization
2 Exemption based on IRC 501(c)(4) Federal Determination Letter
Check the organization’s primary purpose and activity:
m Civic league m Local association of m Social welfare m Service clubs m Veterans’ organization
employees
m Legislative activities m Festival organizations m Municipal building m Police, sheriff, m Quasi governmental
corporation volunteer firemen
association
3 Exemption based on IRC 501(c)(5) Federal Determination Letter
Check the organization’s primary purpose and activity:
m Agriculture m Horticulture m Labor m Agriculture or horticulture county fair m Public employees union
m AFL-CIO m Independent m Transportation m Teamsters
workers
4 Exemption based on IRC 501(c)(6) Federal Determination Letter
Check the organization’s primary purpose and activity:
m Board of trade m Business league m Chamber of commerce m Real estate board m Professional association or society
5 Exemption based on IRC 501(c)(7) Federal Determination Letter
Check the organization’s primary purpose and activity:
m Social and recreational m Golf club m Camps m Fraternity or sorority m Dog or horse club
m Car, motorcycle, m Hunting or m Common recreational m Flying or airplane club
trailer club fishing club area
6 Exemption based on IRC 501(c)(19) Federal Determination Letter
Check the organization’s primary purpose and activity:
m Veterans’ organization
8092173
