ST-119.2: New York Application for an Exempt Organization Certificate

Enter the name of organization, the organization's telephone number, the physical address (number and street), City, State and ZIP code, the mailing address, City, State and ZIP code, the name and title of the person to be contacted (see instructions), that person's telephone number, email address and fax number, the date formally organized, the date incorporated and the employer identification number.

Mark an X in the appropriate box to indicate the Tax Law section under which you are claiming exempt status.

Under 1a, § 1116(a)(4), mark an X in the appropriate box to indicate the purpose for which you are claiming exempt status (see instructions).

Religious, Testing for public safety, Prevention of cruelty to children or animals, Charitable, Scientific, Fostering national or international amateur sports competition, Educational, Literary.

Under 1b, § 1116(a)(5), a post or organization organized in New York State of past or present members of the United States armed forces, or an auxiliary unit or society of, or a trust or foundation for, any such post or organization organized in New York State (see instructions).

Enter what percentage of your members are past or present members of the United States armed forces, what percentage are cadets or are spouses, widows, widowers, ancestors, or lineal descendants of past or present members of the United States armed forces or of cadets, and what percentage do not fall within either of these categories.

If the post or organization has received a federal ruling on its exemption claim, attach a copy of the federal determination letter confirming your Internal Revenue Code (IRC) § 501(c)(19) exemption.

Under 1c, § 1116(a)(6), this form is optional for Indian nations or tribes residing in New York State: Cayuga, Oneida, Onondaga, Poospatuck, Saint Regis Mohawk, Seneca, Shinnecock, Tonawanda and Tuscarora, and their wholly owned entities. This form must be signed by the governing chief or member of the ruling body of the Indian nation or tribe. The remainder of the form does not need to be completed. Skip to the Certification section (see instructions).

Under 1d, § 1116(a)(7), a not-for-profit corporation acting as a health maintenance organization subject to the provisions of Public Health Law Article 44. You must attach a copy of the certificate of authority issued by the New York State Health Department.

Under 1e, § 1116(a)(8), a cooperative or foreign corporation doing business in this state pursuant to the Rural Electric Cooperative Law.

Under 1f, § 1116(a)(9), a credit union, as defined by New York State Banking Law § 2(9), where it is the purchaser, user, or consumer of services or property, or where it is a vendor of services or property of a kind not ordinarily sold by private persons (see instructions).

2: Are you currently registered for sales tax purposes with the Tax Department? Yes No. If Yes, enter your sales tax identification number.

If you answer Yes to questions 3 through 7, attach an explanation (see instructions).

3: Has any distribution of the organization's property ever been made to shareholders, members, or other individuals? Yes No.

4: Does any part of the net earnings of the organization go to the benefit of any private shareholder or individual? Yes No.

5: If you marked box 1a, has the organization ever attempted to influence legislation? Yes No.

6: If you marked box 1a, has the organization ever participated or intervened, directly or indirectly, in any political campaign or endorsed or opposed any candidate for public office? Yes No.

7: If you marked box 1a and the organization fosters national or international amateur sports competition, does it provide any facilities or equipment, either directly or indirectly, to anyone? Yes No.

8: Has the organization received an exemption from federal income tax under IRC § 501(c)(3)? Yes No. If Yes, you must attach a copy of the federal determination letter confirming your IRC § 501(c)(3) exemption. 9: If you are a branch or chapter, has your parent organization received an exemption from federal income tax under IRC § 501(c)(3) that applies to subordinate branches or chapters (see instructions)? Yes No. If Yes, you must attach a copy of the federal determination letter confirming your IRC § 501(c)(3) exemption.

10: Mark an X in the appropriate box to indicate your type of organization (see instructions).

Corporation (attach a copy of articles of incorporation, including filing receipt, and bylaws and any amendments to either of them). Trust or foundation (attach a copy of Declaration of Trust and bylaws and any amendments to either of them). Limited liability company (LLC) (attach a copy of articles of organization and operating agreement and any amendments to either of them). Credit union (attach a copy of federal or New York State charter). Other (attach a copy of constitution and bylaws and any amendments to either of them).

11: Attach the following to this application (see instructions): Statement of activities fully describing all current and proposed activities.

Attach a statement of receipts and expenditures for your most recent fiscal year of operation, clearly reflecting the nature and amount of receipts and the purpose and amount of expenditures. If you have been in existence less than a year, submit a statement of your receipts and expenditures to date, and a proposed budget for the rest of the year.

Attach a statement of assets and liabilities as of the end of your most recent fiscal year. If you have been in existence less than a year, your statement should be as of the date of this application.

Do not attach federal Form 1023, Application for Recognition of Exemption.

The Tax Department may require the applicant to submit additional documents and information.

By signing you certify that these statements are true, complete, and correct, and that no material information has been omitted.

Name and title of officer, trustee, governing chief, or member of the ruling body (print name and title).

Email address of officer, trustee, governing chief, or member of the ruling body.

You make these statements with the knowledge that willfully providing false or fraudulent information with this document may constitute a felony or other crime under New York State Law, punishable by a substantial fine and possible jail sentence.