California Submission of Exemption Request and Instructions

Submission of Exemption Request and Instructions
California Form 3500 A, Submission of Exemption Request
Submission of Exemption Request

CALIFORNIA FORM

3500A

Exemption Based on Internal Revenue Code (IRC) Sections 501(c)(3), 501(c)(4), 501(c)(5),
501(c)(6), 501(c)(7), or 501(c)(19) Federal Determination Letter

Enclose a copy of the Federal Determination Letter.
Organization Information
California corporation number/California Secretary of State file number

FEIN

Name of organization as shown in the organization’s creating document

Web address

Street address (suite, room, or PMB no.)
City

State

Telephone

Second telephone

ZIP code

Fax

Representative Information
Name of representative

Email address

Representative’s mailing address (suite, room, or PMB no.)
City

State

Telephone

Part I
1

Second telephone

ZIP code

Fax

Entity Information. See instructions.

Has the Franchise Tax Board previously revoked the entity’s tax-exempt status?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

□ Yes

□ No
□ No

If “Yes,” STOP. File form FTB 3500.
2

Is the entity a trust? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

□ Yes

3

When did the organization establish, incorporate, organize, or conduct business in California? Example: mm/dd/yyyy . . . . . 3

____ / ____ / ____

4

Provide gross receipts for the current year and the three immediately preceding taxable years in existence. Gross receipts
are defined as the total amounts the organization received from all sources during its annual account period without
subtracting any costs or expenses. If the organization has been in existence for less than one year, provide the projected
amount of gross receipts for the entire year. List the account period beginning to the account period ending. Example: mm/dd/yyyy
Current Year or Projected
Gross Receipts
From:
To:

Part II
5

Gross Receipts for the three immediately preceding taxable years:
From:
To:

From:
To:

From:
To:

Group Exemption. See instructions.

Is the parent organization applying for a group exemption? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

□ Yes

□ No

□ Yes

□ No

If “Yes,” attach the federal group determination letter and a list of all California subordinates. Include each subordinate’s name,
California corporation number, federal employer identification number (FEIN), address, and affiliation date.
6

Is a subordinate unit applying for tax-exempt status using a parent’s Internal Revenue Service group determination letter?
If “Yes,” see instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Mail form FTB 3500A and a copy of the federal determination letter to:
EXEMPT ORGANIZATIONS UNIT, MS F120, FRANCHISE TAX BOARD, PO BOX 1286, RANCHO CORDOVA CA 95741-1286.
Under penalties of perjury, I declare I have examined this submission for exemption based on the IRC Sections 501(c)(3), 501(c)(4), 501(c)(5),
501(c)(6), 501(c)(7), or 501(c)(19), federal determination letter, and to the best of my knowledge and belief, it is true, correct, and complete.

DATE

SIGNATURE OF OFFICER OR REPRESENTATIVE

8091233

TITLE

FTB 3500A 2023 Side 1

Part III
1

Purpose and Activity

Exemption based on IRC Section 501(c)(3) Federal Determination Letter
Check the organization’s primary purpose and activity:

□ Charitable
□ Mosque
□ Testing for public safety
□ Literary
2

□ Hospital
□ Church
□ Qualified sports organization
□ Scientific

□ Health care center
□ Temple
□ Prevent cruelty to animals
□ Religious

□ Educational
□ Synagogue
□ Prevent cruelty to children
□ School

Exemption based on IRC Section 501(c)(4) Federal Determination Letter
Check the organization’s primary purpose and activity:

□ Civic league

□ Local association of

□ Social welfare

□ Service clubs

□ Veterans’ organization

□ Municipal building

□ Police, sheriff,

□ Quasi governmental

employees

□ Legislative activities

□ Festival organizations

corporation
3

volunteer firemen
association

Exemption based on IRC Section 501(c)(5) Federal Determination Letter
Check the organization’s primary purpose and activity:

□ Agriculture
□ AFL-CIO

□ Horticulture
□ Independent

□ Labor
□ Transportation

□ Agriculture or horticulture county fair
□ Teamsters

□ Public employees union

workers
4

Exemption based on IRC Section 501(c)(6) Federal Determination Letter
Check the organization’s primary purpose and activity:

□ Board of trade
5

□ Business league

□ Real estate board

Exemption based on IRC Section 501(c)(7) Federal Determination Letter
Check the organization’s primary purpose and activity:
□ Social and recreational
□ Golf club
□ Camps

□ Car, motorcycle,

□ Hunting or

trailer club
6

□ Chamber of commerce

fishing club

□ Common recreational
area

Exemption based on IRC Section 501(c)(19) Federal Determination Letter
Check the organization’s primary purpose and activity:

□ Veterans’ organization

Side 2

FTB 3500A

2023

8092233

□ Professional association or society

□ Fraternity or sorority
□ Flying or airplane club

□ Dog or horse club