EXEMPTION REQUEST
WARNING: False or misleading statements
Subject to maximum $5,000 civil penalty. T.C.A. §48-101-514
State of Tennessee
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
EXEMPTION REQUEST
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 prin-
cipal offi cer of the organization must sign the form in the pres-
ence of a notary public.
1. Name of Organization: FEIN:
2. Physical Address:
(Street)
(City)
(State)
(Zip)
3. Mailing Address (if different):
(Street)
(City)
(State)
(Zip)
4. Telephone Number: ( ) 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 Association Other (specify)
B. When and where was the legal entity organized? Date: 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 fi led with the IRS, complete the attached "Summary of Financial Activities" form with fi nancial
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 of Owner / Authorized Offi cer
Print Name
Title
Date
SS-6042 (Rev. 04/09)
RDA 1742
Signature
This document must be signed by an authorized offi cer. 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.
Print Form