rom 5168

(March 1977)

Department of the Treasury
Internal Revenue Service

Election/Revocation of Election by an Eligible
Section 501(c)(3) Organization to Make

Expenditures to Influence Legislation
(Under Section 501 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 the applicable subsection of 501 of
the Code, relating to expenditures by public charities to influence legislation, apply to our taxable year ending

(Month, day, and year)
Note: This election must be signed and postmarked within the first taxable year to which it applies.

., and all subsequent taxable years until revoked.

2 Revocation.—As an eligible organization we hereby revoke our election to have the provisions of the applicable sub-

section of 501 of the Code, relating to expenditures to influence legislation, apply to our taxable year ending ..

(Month, day, and year)

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

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

of the above named organization.

Wate)

Instructions

(References are to the Internal Revenue Code)

Section 501(c)(3) of the Code 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
legistation. The applicable subsection under
section 501, however, permits certain eli-
gible 501(c)(3) organizations to elect to
make limited expenditures to influence leg-
islation. The election is only applicable to
taxable years beginning after December 31,
1976. 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. Fur-
thermore, the organization may lose its
exempt status if its lobbying expenditures
exceed the permitted amounts by more than
50 percent over a four-year period. For any
taxable year in which an election under sec-
tion 501 is in effect, an electing organi-
zation must report the actual and permitted
amounts of its lobbying expenditures and
grass roots expenditures (as defined in sec-
tion 4911(c)) on its annual return required
under section 6033. Each electing member
of an affiliated group must report the above
amounts as to both itself and the affiliated
group as a whole.

The election or revocation of election is
made by entering the ending date of the tax-
able year to which the Election or Revoca-
tion applies in item 1 or 2 as is applicable
and by entering the date signed and the sig-
nature and title of the officer or trustee
authorized to make the election or revoca-
tion in the appropriate spaces on this form.

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

(a) section 170(b)(1)(A)(ii) (relating to
educational institutions),

(b) section 170(b)(1)(A)(iii) (relating to
hospitals and medical research or-
ganizations),

(c) section 170(b)(1)(A)(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 organi-
zations publicly supported by admis-
sions, sales, etc.), or

(f) section 509(a)(3) (relating to organi-
zations supporting certain types of
public charities other than those sec-
tion 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
a convention or association of
churches, or

(c) a member of an affiliated group of or-
ganizations if one or more members
Of such group is described in (a) or
(b) above.

Affiliated Organizations.—Organizations
are members of an affiliated group of or-
ganizations only if—(1) the governing in-
strument of one such organization requires it
to be bound by the decisions of the other or-
ganization on legislative issues, or (2) the
governing board of one such organization
includes persons who (i) are specifically des-
ignated representatives of another such or-
ganization or are members of the governing
board, officers, or paid executive staff mem-
bers of such other organization and (ii) by
aggregating their votes have sufficient vot-
ing power to cause or prevent action on leg-
islative issues by the first such organization.

For further details, see section 4911 and
the applicable subsection of section 501.

Note: A private foundation (including a
private operating foundation) is not an eli-
gible organization.

Where to File.—

If principal office
of the organization
is located in:

‘Send
election/revocation
form to:

Connecticut, New Hampshire, Internal Revenue Service

Maine, Massachusetts, Center
Rhode Island, and Vermont 310 Lowell Street

‘Andover, Mass. 01812
Indiana, Kentucky, Internal Revenue Service
Michigan, Ohio, and Center

West Virginia Cincinnati, Ohio 45298

Internal Revenue Service
Center

5045 East Butler Avenue

Fresno, Calif. 93888

Arizona, California,
Hawaii, Nevada, and
Utah

All other States, U.S.
possessions and
foreign countries

Internal Revenue Service
Center

11601 Roosevelt Boulevard

Philadelphia, Pa, 19155

218-283-1

‘Ye U.S, GOVERNMENT PRINTING OFFICE : 1977—-O-218-283,

Form 5768 (3-77)