Election/Revocation of Election by an Eligible

Section 501(c)(3) Organization To Make

Expenditures To Influence Legislation

Form 5768

(Rev. September 2009)

For IRS

Use Only © Department of the Treasury

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

Name of organization Employer identification number

Number and street (or P.O. box no., if mail is not delivered to street address)

City, town or post office, and state

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 and

all subsequent tax years until revoked.

1

(Month, day, and year)

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

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

2

(Month, day, and year)

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

Under penalties of perjury, I declare that I am authorized to make this (check applicable box) ©

(Signature of officer or trustee) (Type or print name and title) (Date)

2. Section 170(b)(1)(A)(iii) (relating to

hospitals and medical research

organizations),

General Instructions

Section references are to the Internal

Revenue Code.

3. Section 170(b)(1)(A)(iv) (relating to

organizations supporting government

schools),

Section 501(c)(3) states 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 section

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. Also, 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

4911(c)) on its annual return required

under section 6033. See Part II-A of

Schedule C (Form 990 or Form 990-EZ).

Each electing member of an affiliated

group must report these amounts for

both itself and the affiliated group as a

whole.

For more details, see section 4911

and section 501(h).

4. Section 170(b)(1)(A)(vi) (relating to

organizations publicly supported by

charitable contributions),

Note. A private foundation (including a

private operating foundation) is not an

eligible organization.

5. Section 509(a)(2) (relating to

organizations publicly supported by

admissions, sales, etc.), or

Where to file. Mail Form 5768 to the

Department of the Treasury, Internal

Revenue Service Center, Ogden, UT

84201-0027.

6. 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. A member of an affiliated group of

organizations if one or more members

of such group is described in a or b

of this paragraph.

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.

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 (i)

who 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) who, by

aggregating their votes, have sufficient

voting power to cause or prevent action

on legislative issues by the first such

organization.

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:

1. Section 170(b)(1)(A)(ii) (relating to

educational institutions),

Cat. No. 12125M Form 5768 (Rev. 9-2009)

Room/suite

ZIP + 4

election revocation

on behalf of the above named organization.