Form RW Page 1 of 2 (Rev.12/10) Elaine F. Marshall, Secretary of State 26 U.S.C. 501(c) (3) Nonprofit Fee Reduction/Waiver Request 2011 Please attach the original of this form to the Principal registration authorization statement and a copy of the signed original to each lobbyist 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 G.S. §120C, Article 2, and in support has attached or provided below all necessary information or documentation for the requested fee reduction or waiver. See page 2 of this form for required fee amount. ALL 3 CRITERIA MUST BE MET FOR FEE REDUCTION: 1. 2. 3. 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 a copy to this request 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, 2010. The principal has attached 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 ____________ ______________________________________________________________________. ALL 4 CRITERIA MUST BE MET FOR FEE WAIVER: 1. 2. 3. 4. 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 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 ____________ _______________________________________________________________________. If all required information and correct fee amount is not submitted at time of registration, the filing will be rejected. American LegalNet, Inc. www.FormsWorkFlow.com Form RW Page 2 of 2 (Rev.12/10) The undersigned authorized officer of the principal hereby certifies that all the information disclosed and in the attachments 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. ** 18 NCAC 12 .0418. (1) A $50.00 fee must be submitted by the principal for the first Principal Registration Lobbyist Authorization Statement and a $50.00 fee must be submitted with every Lobbyist 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 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