OMB No. 1545-1879 Exempt Organization Declaration and Signature for

Electronic Filing Form 8453-EO

Department of the Treasury

Internal Revenue Service

For calendar year 2009, or tax year beginning , 2009, and ending , 20

Name of exempt organization Employer identification number

Type of Return and Return Information (Whole Dollars Only)

Declaration of Officer

Declaration of Electronic Return Originator (ERO) and Paid Preparer (see instructions)

For Privacy Act and Paperwork Reduction Act Notice, see back of form. Cat. No. 36606Q Form 8453-EO (2009)

Part III

Part I

Part II

For use with Forms 990, 990-EZ, 990-PF, 1120-POL, and 8868

Check the box for the return for which you are using this Form 8453-EO and enter the applicable amount, if any, from the return.

If you check the box on line 1a, 2a, 3a, 4a, or 5a below and the amount on that line for the return for which you are filing this form

was blank, then leave line 1b, 2b, 3b, 4b, or 5b, whichever is applicable, blank (do not enter -0-). If you entered -0- on the return,

then enter -0- on the applicable line below. Do not complete more than one line in Part I.

Sign

Here Signature of officer Title

Date Check ERO’s SSN or PTIN

if selfemployed

ERO’s ERO’s signature

Use

Only

Firm’s name (or

yours if self-employed),

address, and ZIP code

EIN

Phone no. ( )

Under penalties of perjury, I declare that I have examined the above return and accompanying schedules and statements, and to the best of my knowledge

and belief, they are true, correct, and complete. Declaration of preparer is based on all information of which the preparer has any knowledge.

Date Check Preparer’s SSN or PTIN

if selfemployed

Preparer’s Paid signature

Preparer’s

Use Only

Firm’s name (or

yours if self-employed),

address, and ZIP code









EIN

Check if

also paid

preparer

I authorize the U.S. Treasury and its designated Financial Agent to initiate an ACH electronic funds withdrawal (direct debit) entry

to the financial institution account indicated in the tax preparation software for payment of the organization’s federal taxes owed

on this return, and the financial institution to debit the entry to this account. To revoke a payment, I must contact the U.S. Treasury

Financial Agent at 1-888-353-4537 no later than 2 business days prior to the payment (settlement) date. I also authorize the financial

institutions involved in the processing of the electronic payment of taxes to receive confidential information necessary to answer

inquiries and resolve issues related to the payment.

See instructions on back.

Under penalties of perjury, I declare that I am an officer of the above named organization and that I have examined a copy of the

organization’s 2009 electronic return and accompanying schedules and statements and to the best of my knowledge and belief, they are

true, correct, and complete. I further declare that the amount in Part I above is the amount shown on the copy of the organization’s

electronic return. I consent to allow my intermediate service provider, transmitter, or electronic return originator (ERO) to send the

organization’s return to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection of the transmission,

(b) an indication of any refund offset, (c) the reason for any delay in processing the return or refund, and (d) the date of any refund.

I declare that I have reviewed the above organization’s return and that the entries on Form 8453-EO are complete and correct to the best

of my knowledge. If I am only a collector, I am not responsible for reviewing the return and only declare that this form accurately reflects

the data on the return. The organization officer will have signed this form before I submit the return. I will give the officer a copy of all

forms and information to be filed with the IRS, and have followed all other requirements in Pub. 4163, Modernized e-File (MeF) Information

for Authorized IRS e-file Providers for Business Returns. If I am also the Paid Preparer, under penalties of perjury I declare that I have

examined the above organization’s return and accompanying schedules and statements, and to the best of my knowledge and belief, they

are true, correct, and complete. This Paid Preparer declaration is based on all information of which I have any knowledge.

Phone no. ( )

Date

1a Form 990 check here b Total revenue, if any (Form 990, Part VIII, column (A), line 12) 1b

2a Form 990-EZ check here b Total revenue, if any (Form 990-EZ, line 9) 2b

3a Form 1120-POL check here b Total tax (Form 1120-POL, line 22) 3b

4a Form 990-PF check here b Tax based on investment income (Form 990-PF, Part VI, line 5) 4b

5a Form 8868 check here b Balance due (Form 8868, line 3c) 5b

6

If a copy of this return is being filed with a state agency(ies) regulating charities as part of the IRS Fed/State program, I certify that

I executed the electronic disclosure consent contained within this return allowing disclosure by the IRS of this Form

990/990-EZ/990-PF (as specifically identified in Part I above) to the selected state agency(ies).

2009
Privacy Act and Paperwork Reduction Act Notice. We ask for

the information on this form to carry out the Internal Revenue

laws of the United States. You are required to give us the

information. We need it to ensure that you are complying with

these laws and to allow us to figure and collect the right amount

of tax. Section 6109 requires return preparers to provide their

identifying numbers on the return.

The time needed to complete and file this form will vary

depending on individual circumstances. The estimated average Part II. Declaration of Officer time is:

Part III. Declaration of Electronic Return

Originator (ERO) and Paid Preparer

How To File

When To File

Form 990, Form 990-EZ, and Form 990-PF. File Form 990,

Form 990-EZ, or Form 990-PF by the 15th day of the 5th month

after the organization’s accounting period ends. If the regular

due date falls on a Saturday, Sunday, or legal holiday, the

organization may file on the next business day. The Form

8453-EO must be filed with the electronically filed Form 990,

Form 990-EZ, or Form 990-PF.

Use Form 8453-EO to:

● Authorize the electronic return originator (ERO), if any, to

transmit via a third-party transmitter;

● Authorize an electronic funds withdrawal for payment of

federal taxes owed (Form 990-PF, Form 1120-POL, or Form

8868 with payment).

Purpose of Form

You are not required to provide the information requested on a

form that is subject to the Paperwork Reduction Act unless the

form displays a valid OMB control number. Books or records

relating to a form or its instructions must be retained as long as

their contents may become material in the administration of any

Internal Revenue law. The rules governing the confidentiality of

the Form 990, Form 990-EZ, and Form 990-PF are covered in

section 6104. Generally, tax returns (Form 1120-POL) and return

information are confidential, as required by section 6103.

If a Form 990-PF, Form 1120-POL, or Form 8868 filer chooses

to pay the tax due by electronic funds withdrawal (direct debit),

check the box. Otherwise, leave the box blank.

Form 8453-EO (2009) Page 2

Form 1120-POL. File Form 1120-POL by the 15th day of the 3rd

month after the organization’s accounting period ends. If the

regular due date falls on a Saturday, Sunday, or legal holiday,

the organization may file on the next business day. The Form

8453-EO must be filed with the electronically filed Form

1120-POL.

Recordkeeping 4 hr., 32 min.

Learning about the law or the form 18 min.

Preparing, copying, assembling, 

and sending the form to the IRS 22 min.

If you have comments concerning the accuracy of these time

estimates or suggestions for making this form simpler, we would

be happy to hear from you. You can write to the Internal

Revenue Service, Tax Products Coordinating Committee,

SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6526,

Washington, DC 20224. Do not send Form 8453-EO to this

address. Instead, see How To File on this page.

Instead of filing Form 8453-EO, an organization

officer filing an exempt organization’s return through

an electronic return originator (ERO) can sign the

return using a personal identification number (PIN).

For details, see Form 8879-EO, IRS e-file Signature Authorization

for an Exempt Organization.

● Authenticate the electronic Form 990, Return of Organization

Exempt From Income Tax; Form 990-EZ, Short Form Return of

Organization Exempt From Income Tax; Form 990-PF, Return of

Private Foundation; Form 1120-POL, U.S. Income Tax Return for

Certain Political Organizations; or Form 8868, Application for

Extension of Time To File an Exempt Organization Return;

● Authorize the intermediate service provider (ISP) to transmit via

a third-party transmitter if you are filing online (not using an

ERO); and

Who Must File

If you are filing a 2009 Form 990, Form 990-EZ, Form 990-PF,

Form 1120-POL, or Form 8868 with payment through an ISP

and/or transmitter and you are not using an ERO, you must file

Form 8453-EO with your electronically filed return. An ERO can

use either Form 8453-EO or Form 8879-EO to obtain

authorization to file an organization’s Form 990, Form 990-EZ,

Form 990-PF, or Form 1120-POL, or to file a Form 8868 with

payment.

File Form 8453-EO with the organization’s electronically filed

return. Use a scanner to create a PDF file of the completed form.

Your tax preparation software will allow you to transmit this PDF

file with the return.

If the officer checks the box when filing Form 990-PF, Form

1120-POL, or Form 8868 with payment, the officer must ensure

that the following information relating to the financial institution

account is provided in the tax preparation software.

● Routing number,

● Account number,

● Type of account (checking or savings),

● Debit amount, and

● Debit date (date the organization wants the debit to occur).

● Form 8453-EO is signed by an organization officer, scanned

into a PDF file, and transmitted with the return, or

● The return is filed through an ERO and Form 8879-EO is used

to select a personal identification number (PIN) that is used to

electronically sign the return.

The officer’s signature allows the IRS to disclose to the ISP,

ERO, and/or transmitter:

● An acknowledgment that the IRS has accepted the

organization’s electronically filed return,

● The reason(s) for a delay in processing the return or refund, and

● If a refund offset may occur.

The declaration of officer must be signed and dated by:

● The president, vice president, treasurer, assistant treasurer,

chief accounting officer, or

● Any other organization officer authorized to sign the

organization’s return.

Note. If the return is filed online through an ISP and/or

transmitter (not using an ERO), do not complete the ERO’s Use

Only section in Part III.

If the organization’s return is filed through an ERO, the IRS

requires the ERO’s signature. A paid preparer, if any, must sign

Form 8453-EO in the space for Paid Preparer’s Use Only. But if

the paid preparer is also the ERO, do not complete the paid

preparer’s section. Instead, check the box labeled Check if also

paid preparer.

An electronically transmitted return will not be considered

complete (and therefore not considered filed) unless either:

TIP

Form 8868. Generally, file Form 8868 by the due date of

the return for which you are requesting an extension. The Form

8453-EO must be filed with the electronically filed Form 8868.

If this return contains instructions to the IRS to provide a

copy(ies) of the return to a state agency(ies) regulating charities

as part of the IRS Fed/State program, the checkbox in Part II

must be checked.