Form RW Page 1 of 2 (Rev.12/08) Please type, print in ink or complete on line Office use only:____ File # Elaine F. Marshall, Secretary of State 501(c) (3) Nonprofit Fee Reduction/Waiver Request 2009 PLEASE ATTACH THE ORIGINAL OF THIS REDUCTION/WAIVER FORM TO THE PRINCIPAL’S REGISTRATION/LOBBYIST AUTHORIZATION STATEMENT AND A COPY OF THE SIGNED ORIGINAL TO EACH LOBBYIST’S REGISTRATION STATEMENT Full Legal Name of Principal: _____________________________________________________________ Lobbyist(s): 1. ______________________________ 2. ________________________________________ The principal, by and through its undersigned authorized officer, hereby verifies that it meets all the Department’s specified criteria for requesting a  reduction or  waiver of lobbying registration fees pursuant to NCGS §120C, Article 2, and in support thereof has attached hereto or states below all necessary information or documentation for the requested fee reduction or waiver (principal must satisfy all applicable requirements): For Reduction:    The principal has no more than two (2) lobbyists and the name of each such lobbyist has been entered above. The principal had revenues in its most recent fiscal year of $300,000.00 or less and has attached hereto a copy of its most recent federal Form 990, Form 990-EZ or Form 990-PF or hereby states that the principal is not required to file such form and has attached hereto a copy of its annual financial statement for the preceding tax year, together with a copy of the notice filed pursuant to Section 1223 of the United States Pension Protection Act of 2006 (PL 109-280) for notices and returns associated with annual periods beginning on or after January 1, 2008. The principal has attached hereto a copy of its federal tax-exempt determination letter or hereby states that the principal has been granted federal tax-exempt status under 26 U.S.C. Section 501(c)(3) without the requirement of a determination letter because ________________ _________________________________________________________________________________. For Waiver:     The principal has no more than two (2) lobbyists and the name of each such lobbyist has been entered above. The principal was formed within 12 months of this request on ____________________________. The principal does not possess fund balance information or net assets for the immediately preceding fiscal year. The principal has attached hereto a copy of its federal tax-exempt determination letter or hereby states that the principal has been granted federal tax-exempt status under 26 U.S.C. Section 501(c)(3) without the requirement of a determination letter because ________________ _________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com Form RW Page 2 of 2 (Rev.12/08) Office use only:____ The undersigned authorized officer of the principal hereby certifies that all the information disclosed herein and in the attachments hereto is true, complete and correct. _______________________________________________________________________________________ Signature of Authorized Officer Date _______________________________________________________________________________________ Printed Name/Title of Authorized Officer* _______________________________________________________________________________________ Signature of Preparer if other than Authorized Officer Date _______________________________________________________________________________________ Printed Name of Preparer if other than Authorized Officer** * An authorized officer is: (1) A person authorized pursuant to Chapter 55A of the General Statutes to act on behalf of a corporation; (2) A person authorized pursuant to Chapter 36C of the General Statutes or other law to act on behalf of a nonprofit trust; or (3) A person to whom a nonprofit association has delegated authority to act on behalf of the association. **Per Rule NCAC 12.0418 (1) A reduced $50.00 fee must be submitted by the principal and each of its lobbyists with their respective registrations, payable by cash, check, money order, credit card or another instrument freely negotiable at par through the Federal Reserve System. Checks, money orders, credit cards or other instruments must be drawn on U.S. financial institutions in U.S. dollars and cents. A filing is void if a check or other instrument for a required fee is returned by the institution upon which it was issued as “insufficient funds” or for other similar reason. (2) If a waiver of fees is granted, the Department will refund the $50.00 fees submitted by the principal and each of its lobbyists. (3) In the event the Department determines that the principal does not qualify for a reduction of registration fees, the remaining $50.00 for the principal and each of its lobbyists must be paid within 10 business days of the date of the Department’s denial. If the full fees are not so paid, the registration is void and the nonpaying registrant shall not lobby after the 10th business day following the date on the Department’s denial letter. _______________________________________________________________________________________ FOR DEPARTMENT USE ONLY Approved by: _______________________________________ Date: _____________________________ Denied by: __________________________________________ Date: _____________________________ American LegalNet, Inc. www.FormsWorkflow.com