FTB 3500A þ 2018 þ Side 1 en-USSubmission of Exemption Request CALIFORNIA FORM3500A en-USEnclose a copy of the Federal Determination Letter. en-USOrganization Informationen-USRepresentative Informationen-USPart I 227 en-USEntity Information. en-USSee instructions. Name of representativeEmail addressRepresentative222s mailing address (suite, room, or PMB no.)CityStateZIP codeTelephone ( þ ) Second telephone ( þ ) Fax ( þ ) 1 þ Has the Franchise Tax Board (FTB) previously revoked the entity222s tax-exempt status?. þ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................. þ 1 þ 037 Yes þ 037 No þ If 223Yes,224 STOP. File form FTB 3500. 2 þ Is the entity a trust? þ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................................................................. þ 2 þ 037 Yes þ 037 No 3 þ When did the organization establish, incorporate, organize, or conduct business in California? þ . . . . . . . . . . . . . . . . . . . . . . ....................... þ 3 þ / / 4 þ Provide gross receipts for the current year and the three immediately preceding taxable years in existence. Gross receipts are de037ned 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 ReceiptsGross Receipts for the three immediately preceding taxable years:From:From:From:From:To:To:To:To:mm dd yyyyen-USPart II 227 en-USGroup Exemption. en-USSee instructions. 5 þ Is the parent organization applying for a group exemption? þ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................................................. þ 5 þ 037 Yes þ 037 No þ If 223Yes,224 attach the federal group determination letter and a list of all California subordinates. Include each subordinate222s name, þ corporation number, Federal employer identi037cation number (FEIN), address, and af037liation date. 6 þ Is a subordinate unit applying for tax-exempt status using a parent222s IRS group determination letter? þ If 223Yes,224 see instructions þ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................................................................. þ 6 þ 037 Yes þ 037 No þ þ þ DATE þ SIGNATURE OF OFFICER OR REPRESENTATIVE þ TITLE8091183 ---en-USExemption Based on Internal Revenue Code (IRC) Sections 501(c)(3), 501(c)(4), 501(c)(5), en-US501(c)(6), 501(c)(7), or 501(c)(19), Federal Determination Letteren-USMail form FTB 3500A and a copy of the federal determination letter to: en-US en-USEXEMPT ORGANIZATIONS UNIT, MS F120, FRANCHISE TAX BOARD, PO BOX 1286, en-USRANCHO CORDOVAen-US CA 95741-1286.en-USUnder 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), en-US501(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. California corporation number/California Secretary of State 037le numberFEIN Name of organization as shown in the organization222s creating documentWeb addressStreet address (suite, room, or PMB no.)CityStateZIP codeTelephone ( þ ) Second telephone ( þ ) Fax ( þ ) American LegalNet, Inc. www.FormsWorkFlow.com FTB 3500A þ 2018 þ Side 2 en-USPart III 227 en-USPurpose and Activity 1 þ Exemption based on IRC 501(c)(3) Federal Determination Letter Check the organization222s primary purpose and activity: þ 037 Charitable þ 037 Educational þ 037 Literary þ 037036 Prevent cruelty to animals þ 037 Prevent cruelty to children þ 037 Testing for public safety þ 037 Religious þ 037 Scienti037c þ 037036 Church þ 037036School þ 037 Hospital þ 037 Health care center þ 037 Quali037ed sports organization 2 þ Exemption based on IRC 501(c)(4) Federal Determination Letter Check the organization222s primary purpose and activity: þ 037 Civic league þ 037 Local association of þ 037 Social welfare þ 037036 Service clubs þ 037 Veterans222 organization þ employees þ þ 037 Legislative activities þ 037 Festival organizations þ 037 Municipal building þ 037036 Police, sheriff, þ 037036Quasi governmental þ þ corporation þ volunteer 037remen þ association 3 þ Exemption based on IRC 501(c)(5) Federal Determination Letter Check the organization222s primary purpose and activity: þ 037 Agriculture þ 037 Horticulture þ 037 Labor þ 037036 Agriculture or horticulture county fair þ 037 Public employees union þ 037 AFL-CIO þ 037 Independent þ 037 Transportation þ 037036Teamsters þ workers 4 þ Exemption based on IRC 501(c)(6) Federal Determination Letter Check the organization222s primary purpose and activity: þ 037 Board of trade þ 037 Business league þ 037 Chamber of commerce þ 037036 Real estate board þ 037 Professional association or society 5 þ Exemption based on IRC 501(c)(7) Federal Determination Letter Check the organization222s primary purpose and activity: þ 037 Social and recreational þ 037 Golf club þ 037 Camps þ 037036 Fraternity or sorority þ 037 Dog or horse club þ 037 Car, motorcycle, þ 037 Hunting or þ 037 Common recreational þ 037036Flying or airplane club trailer club þ 037shing club þ area 6 þ Exemption based on IRC 501(c)(19) Federal Determination Letter Check the organization222s primary purpose and activity: þ 037 Veterans222 organization8092183 American LegalNet, Inc. www.FormsWorkFlow.com