State of South Carolina Office of the Secretary of State Mark Hammond Public Charities Division APPLICATION FOR EXEMPTION www.scsos.com charities@sos.sc.gov Check one: [ ] Initial Registration Post Office Box 11350 Columbia, SC 29211 [ ] Renewal End of Fiscal Year: ___________________ Employer’s Identification Number: ___ ___ -- ___ ___ ___ ___ ___ ___ ____ 1. Phone: (803) 734-1790 Fax: (803) 734-1604 Registration Number: _________________ Organization's Legal Name __________________________________________________________________________ Other Names Used _________________________________________________________________________________ 2. Contact Person’s Name ___________________________________ Title _____________________________________ Contact Person’s Mailing Address ____________________________________________________________________ City __________________________________ County ______________________ State _______ Zip _____________ Day Phone ( _____ )______________ Evening Phone ( ______ ) ________________ Fax ( ____ ) ________________ Contact Person’s E-mail __________________________________ Organization’s Web Site ______________________ 3. Organization’s Street Address ________________________________________________________________________ ________________________________________________________________________________________________ City __________________________________ County _______________________ State _______ Zip _____________ 4. General purpose of the organization ___________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 5. Basis for exemption according to the Solicitation of Charitable Funds Act of 1994, check ONE of the following: _____ (1) Educational Institution (Schools, colleges, universities, and the foundations of South Carolina colleges and universities) _____ (2) Solicitation for the relief of a specified individual _____ (3) Organizations which do not intend to solicit in excess of $20,000 in a calendar year and have a letter of tax exemption from the IRS, if all of their functions including fundraising activities are conducted by persons who are compensated no more than $500 annually for their services. (Please attach IRS tax letter.) _____ (4) Organization which solicits exclusively from within its own membership, including utility cooperatives _____ (5) Veterans organization which has a congressional charter _____ (6) The State, its political subdivisions, and any agencies or departments thereof which are subject to the disclosure provisions of the Freedom of Information Act _____ (7) Organizations which do not intend to solicit more than $7,500 in a calendar year, regardless of whether or not the solicitation is conducted by professionals OVER X:\Forms\External\Exemption Application.doc Rev. 10/9/07 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com 6. Organization's Purpose Category Complete either Section 1 or Section 2 below. Section 1: Enter up to three NTEE (National Taxonomy of Exempt Entities) Codes here: ____ ____ ____ ____ , ____ ____ ____ ____ , ____ ____ ____ ____ Section 2: Check up to three boxes below that best describe your organization: A. Arts, Culture, Humanities (inc. historical) B. Educational Institutions (inc. literacy) C. Environment, Beautification (inc. gardening, outdoor education) D. Animal-Related (inc. wildlife sanctuaries) E. Health-General, Rehabilitative (inc. nursing, family planning) F. Mental Health, Crisis Intervention (inc. alcoholism, services for rape and abuse victims) G. Disease, Disorders, Medical Disciplines H. Medical Research I. Crime, Legal-Related (inc. prevention of abuse, delinquency) J. Employment, Job-Related (inc. voc. rehabilitation, unions) K. Agriculture, Food, Nutrition (inc. livestock breeding) L. Housing, Shelter (inc. senior citizen housing) M. Public Safety, Disaster Preparedness and Relief (inc. rescue squads, auto safety) N. Recreation, Sports, Leisure, Athletics (inc. social clubs, Special Olympics) O. Youth Development P. Human Services (inc. thrift stores, YMCAs and YWCAs, hearing- or sight-impaired orgs.) Q. International, Foreign Affairs, National Security (inc. cultural exchange) R. Civil Rights, Social Action, Advocacy (inc. right to life and right to die, reproductive rights) S. Community Improvement, Capacity Building (inc. neighborhood associations, service clubs, bus. development) T. Philanthropy, Volunteerism, Grant-making (inc. foundations) U. Science and Technology Research Institutes (inc. computer science, engineering) V. Social Sciences Institutes (inc. institutes for studies on population, minorities and economics) W. Public Affairs, Society Benefit (inc. citizen participation, consumer protection, veterans' orgs., leadership development) X. Religion, Spiritual Development (inc. religious broadcasters and interfaith coalitions) Y. Mutual / Membership Benefit (inc. fraternal organizations, cemeteries) Z. Unknown, Other Please Specify: ___________________________ CERTIFICATION I certify that the information furnished in this application and all attached supplementary information is true and correct to the best of my knowledge, information and belief. I understand the giving of false or incorrect information may constitute a misdemeanor carrying a penalty upon conviction, for a first offense of not more than two thousand dollars or imprisonment for not more than one year, or both. A second, or subsequent offense is a felony and upon conviction must be fined not more than five thousand dollars or imprisoned not more than five years, or both. Chief Executive Officer: Chief Financial Officer: (Signature) (Signature) (Print Name) (Print Name) (Date) (Date) X:\Forms\External\Exemption Application.doc Rev. 10/9/07 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com