-m 9168

(Rev. January 1990)

Department of the Treasury
internat Revenue Service

Election/Revocation of Election by an Eligible
Section 501(c)(3) Organization To Make
Expenditures To Influence Legislation

(Under Section 501(h) of the Internal Revenue Code)

For IRS
Use Only >»

Name of organization

Employer identification number

Address (number and street)

City or town, state, and ZIP code

1 Election.—As an eligible organization we hereby elect to have the provisions of section 501(h) of the Code, relating to expenditures to

influence legislation, apply to our tax year ending

tax years until revoked.

and all subsequent

(Month, day, and year)

Note: This election must be signed and postmarked within the first taxable year to which it applies.

2. Revocation.—As an eligible organization we hereby revoke our election to have the provisions of section 501(h) of the Code, relating

to expenditures to influence legislation, apply to our tax year ending

Note: This revocation must be signed and postmarked before the first day of the tax year to which it applies.

Under penalties of perjury, | declare that | am authorized to make this (check applicable box) » [ election/ [1 revocation on behalf of

the above named organization.

(Title)

(Date)

Instructions
(References are to the Internal Revenue Code.)

Section 501(c)(3) provides that an
organization exempt under that section will
lose its tax-exempt status and its qualification
to receive deductible charitable contributions
if a substantial part of its activities are carried
on to influence legislation. Section 501(h),
however, permits certain eligible 501(c)(3)
organizations to elect to make limited
expenditures to influence legislation. An
organization making the election will, however,
be subject to an excise tax under section 4911
if it spends more than the amounts permitted
by that section. Furthermore, the organization
may lose its exempt status if its lobbying
expenditures exceed the permitted amounts
by more than 50% over a 4-year period. For
any tax year in which an election under
section 501(h) is in effect, an electing
‘organization must report the actual and
permitted amounts of its lobbying
expenditures and grass roots expenditures (as
defined in section 491 1(c)) on its annual
return required under section 6033. See
Schedule A (Form 990). Each electing
member of an affiliated group must report
these amounts for both itself and the affiliated
group as a whole.

To make or revoke the election, enter the
ending date of the tax year to which the
election or revocation applies in item 1 or 2, as
applicable, and sign and date the form in the
spaces provided.

Eligible Organizations.—A section 501(c)(3)
organization is permitted to make the election
if it is not a disqualified organization (see
below) and is described in:

(a) section 170(bx1)(A)(ii) (relating to
educational institutions),

(b) section 170(b)(1)(A)(iii) (relating to
hospitals and medical research
organizations),

(c) section 170(b){1)(AX(iv) (relating to
organizations supporting government
schools),

(d) section 170(b)(1)(A)vi) (relating to
organizations publicly supported by
charitable contributions),

(e) section 509(a)(2) (relating to
organizations publicly supported by
admissions, sales, etc.), or

(f) section 509(a)(3) (relating to
organizations supporting certain types
of public charities other than those
section 509(a)(3) organizations that
support section 501(c)(4), (5), or (6)
organizations).

Disqualified Organizations.—The following
types of organizations are not permitted to
make the election:

(a) section 170(b){1)(A){i) organizations
(relating to churches),

(b) an integrated auxiliary of a church or
of a convention or association of
churches, or

(c) amember of an affiliated group of
organizations if one or more members
of such group is described in (a) or (b)
of this paragraph.

Affiliated Organizations. —Organizations are
members of an affiliated group of
organizations only if: (1) the governing
instrument of one such organization requires it
to be bound by the decisions of the other
organization on legislative issues, or (2) the
governing board of one such organization
includes persons who (i) are specifically
designated representatives of another such
organization or are members of the governing

board, officers, or paid executive staff
members of such other organization, and (ii)
by aggregating their votes have sufficient
voting power to cause or prevent action on
legislative issues by the first such organization.

For more details, see section 4911 and
section 501(h).

Note: A private foundation (including a
private operating foundation) is not an eligible
organization.

Where To File.—Mail Form 5768 to the

applicable Internal Revenue Service
Center listed below.
Use this address:
v
Rabame, Arkansas, Flonda,
Georgie. Louistana, Atlante, GA 39902

Mississippi, North Carolina,
‘South Carolina, Tennessee

‘Anzona. Colorado, Kansas,
New Mexico, Oklahoma.
Texas, Utah, Wyoming.

Indiana, Kentucky, Michigan:
Ohio, West Virginia

Alaska, California, Hawaii.
Idaho, Nevada, Oregon,
Washington

Connecticut, Delaware, Maine,
Massachusetts, New
Hampshwe, New Jersey, New
York, Pennsylvania (ZIP codes.
baguining wih 169-171 and

73-196 only). Rhode island,
Vermont

libnois, lowa, Minnesota,
Missouri, Montana.

Nebraska, North Dakota,
South Dakota, Wisconsin

Austin, TX 73301

Cincinnati, OH 45999

Fresno, CA 93888

Holtsville, NY 00502

Kansas City, MO 64999

District of Columba, Maryland
Pennsylania (ZIP codes beginning
with 150168 and 172 ony),
Virginia, any U.S. possession, any
foreign country

Philadelphia, PA 19258

U.S. Government Printing Office: 1990-261-151/00057

Form 5768 (Rev. 1-90)