Charitable Law Section Office 614.466.3181 Fax 614.466.9788 150 East Gay Street, 23rd Floor Columbus, Ohio 43215-3130 www.OhioAttorneyGeneral.gov VERIFICATION OF FILING WITH THE INTERNAL REVENUE SERVICE This form is to be completed by 501(c)(3) non-profit organizations, located in Ohio, that file one of the federal tax forms listed below. NOTE: This form should be filed in lieu of a copy of the federal tax return. Do not submit the federal return with this form. I hereby certify that I am a trustee or officer of _____________________________________________________________________________________________ (Name of Organization as filed with the Attorney General’s Office) _____________________________________________________________________________________________ Charity Street Address City Zip Code _____________________________________ _________________________________ (Federal Employer Identification Number) (State Charter Number if applicable) and that the above named organization completed and/or will complete and file: (check one) _____ Form 990 _____ Form 990-PF _____ Form 990-EZ _____ Form 990-N (e-Postcard) required by the Internal Revenue Service for the: (check and complete one of the following) _____ calendar year 2 _ _ _ _____ tax year beginning ______________, 2 _ _ _ , and ending ________________, 2 _ _ _ and that such filing occurred on/or will occur on _____________________________. (Filing Date) Did the organization request a federal extension of time to file this report? ____ Y ____ N If yes, what was/is the extended due date? ___________________________________________________ (Federal Extended Due Date) For fee purposes, please indicate the current total value of assets, or if filing this form prior to an extended federal due date, estimate the current total value of assets, at year end $______________________________ _____________________________________ _______________________________________ Name of Trustee/Officer (Please Print) Telephone number ________________________________________ Signature of Trustee/Officer ___________________________________________ Charitable E-mail Address _____________________________________ Trustee/Officer Title OFFICE USE ONLY FILING FEE PAID _____________________________________ Date Amount __________________ Date _____________________ VFIRS/Revised 2/11 Check #_________________ American LegalNet, Inc. www.FormsWorkFlow.com