Fillable Printable Form 5638 - Non Action Organization Certification

Form 5638 - Non Action Organization Certification

Form

5638

Missouri Department of Revenue

Non Action Organization Certification

This form must be submitted with the offeror’s Request for Proposal (RFP) for License Ofce Management Services by

offerors who are exempt from taxation under Section 501(c)(4) of the Internal Revenue Code of 1986, as amended, in order

to receive credit as an Internal Revenue Service (IRS) Tax Exempt Entity as dened in Section 3.6.1 of the RFP.

RFP Number _____________________________ License Ofce __________________________________________

Legal Name of Entity Filed With IRS

IRS Form 1099 Mailing Address

City State ZIP Code

EntityContact Person

Name

E-mail Address

Telephone Number Federal Employer Identication Number (FEIN)

( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

| | | | | | | |

I hereby declare under penalties of perjury that:

• I am a duly authorized ofcer of the above legal entity, a tax-exempt entity under Section 501(c)(4) of the Internal

Revenue Code of 1986, as amended;

• The above legal entity is not an action organization as dened under 26 C.F.R. Section 1.501(c)(3)-1(c)(3); and

• I understand that pursuant to Section 136.055.2, RSMo that an action organization is not an IRS Tax Exempt entity

as dened in Section 3.6.1 of the License Ofce Request for Proposal.

I solemnly swear or afrm that the facts are true and accurate to the best of my knowledge and belief.

The undersigned understands that false statements made in this ling are subject to the penalties provided under

Section 575.040, RSMo, and are considered a material breach subject to cancellation of the license ofce contract.

Signature

Authorized Signature by Ofcer of Legal Entity Date (MM/DD/YYYY)

___ ___ / ___ ___ / ___ ___ ___ ___

Printed Name Title

Notary Information

Subscribed and sworn before me, this

day of year

State County (or City of St. Louis) My Commission Expires (MM/DD/YYYY)

Notary Public Signature

Notary Public Name (Typed or Printed)

Embosser or black ink rubber stamp seal

__ __ /__ __ /__ __ __ __

Refer all questions to the buyer of record’s e-mail address or telephone number

shown on the rst page of the license ofce RFP, or fax to (573) 526-9816.

License Ofces Bureau Form 5638 (Revised 08-2016)

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