Form 8453-X Political Declaration for Electronic Filing of Notice of

2
TLS, have you
transmitted all R
text files for this
cycle update?

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 4137, PAGE 1 of 2 (page 2 is blank)
MARGINS: TOP 13 mm (1⁄ 2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
FLAT SIZE: 203 mm (8") 3 279 mm (11")
PERFORATE: HORIZONTALLY 4" FROM BOTTOM.

Date

PRINTS: HEAD TO HEAD
INK: BLACK

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form

8453-X

(Rev. September 2008)
Department of the Treasury
Internal Revenue Service

Part I

Action

Date

Signature

O.K. to print
Revised proofs
requested

Political Organization
Declaration for Electronic Filing of
Notice of Section 527 Status

OMB No. 1545-1693

Notice Information

1

Name of organization

2

Mailing address (P.O. box or number, street, and room or suite number)

Employer identification number

City or town, state, and ZIP code

3

Confirmation number

4a

Date Form 8871 filed

Part II

4b Time Form 8871 filed

Declaration
Under penalties of perjury, I declare that the organization named in Part I is to be treated as a tax-exempt organization
described in section 527 of the Internal Revenue Code, that it has filed the electronic Form 8871 referenced above, and that
I have examined that notice, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct, and complete.

Sign
Here

©

©

Signature of authorized official

Date

Instructions
After electronically submitting Form 8871, an
authorized official must sign, date, and send Form
8453-X to:
Department of the Treasury
Internal Revenue Service
Ogden, UT 84201

Upon receipt of this form, the Internal Revenue Service
will send the organization a username and password
that must be used to file an amended or final Form
8871 or to electronically file Form 8872, Political
Organization Report of Contributions and Expenditures.

For Paperwork Reduction Act Notice, see separate Instructions for Form 8871.

Cat. No. 36512T

Form

8453-X

(Rev. 9-2008)