Election/Revocation of Election by an Eligible

Section 501(c)(3) Organization To Make

Expenditures To Influence Legislation

Form 5768

(Rev. January 1994)

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 or town, state, and ZIP code

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) © election revocation

on behalf of the above named organization.

(Signature of officer or trustee) (Title) (Date)

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

hospitals and medical research organizations),

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 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

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.

For more details, see section 4911 and

4. section 501(h). 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

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

organizations publicly supported by

admissions, sales, etc.), or Where To File.—Mail Form 5768 to the

applicable Internal Revenue Service Center

6. Section 509(a)(3) (relating to listed below.

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).

Use this address:

Ä

If the organization’s

principal office is

located in:

Ä

Alabama, Arkansas, Florida,

Georgia, Louisiana,

Mississippi, North Carolina,

South Carolina, Tennessee

Atlanta, GA 39901 Disqualified Organizations.—The following

types of organizations are not permitted to

make the election:

Arizona, Colorado, Kansas,

New Mexico, Oklahoma,

Texas, Utah, Wyoming

a. Section 170(b)(1)(A)(i) organizations Austin, TX 73301

(relating to churches),

Indiana, Kentucky, Michigan,

Ohio, West Virginia b. An integrated auxiliary of a church or of Cincinnati, OH 45999

a convention or association of churches, or Alaska, California, Hawaii,

Idaho, Nevada, Oregon,

Washington

Fresno, CA 93888

Connecticut, Maine,

Massachusetts, New

Hampshire, New York,

Rhode Island, Vermont

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.

Holtsville, NY 00501

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

Illinois, Iowa, Minnesota,

Missouri, Montana,

Nebraska, North Dakota,

South Dakota, Wisconsin

Kansas City, MO 64999

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:

Delaware, District of Columbia,

Maryland, New Jersey,

Pennsylvania, Virginia, any U.S.

possession, or foreign country

Philadelphia, PA 19255

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

educational institutions),

Cat. No. 12125M Form 5768 (Rev. 1-94)

Room/suite

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.