8871 Political Organization

2
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Date

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
Form 8871, PAGE 1 of 4
MARGINS: TOP 13 mm (1⁄2"), CENTER SIDES.
PAPER: WHITE, WRITING, SUB. 20
FLAT SIZE: 203 mm (8") ⫻ 279 mm (11")
PERFORATE: ON FOLD

Action

Date

Signature

O.K. to print

PRINTS: HEAD to HEAD
INK: BLACK

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

Revised proofs
requested

Do not file a paper copy of Form 8871. File electronically only.

Form

8871

Political Organization
Notice of Section 527 Status

(Rev. July 2003)

OMB No. 1545-1693

Department of the Treasury
Internal Revenue Service

Part I

General Information

Name of organization

Employer identification number

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1
2

Mailing address (P.O. box or number, street, and room or suite number)
City or town, state, and ZIP code

3

Check applicable box:

Initial notice

4a Date established

5

Amended notice

Final notice

4b Date of material change

Email address of organization

6a Name of custodian of records

6b Custodian’s address

7a Name of contact person

7b Contact person’s address

8

Business address of organization (if different from mailing address shown above). Number, street, and room or suite number
City or town, state, and ZIP code

9a Election authority

Part II

9b Election authority identification number

Notification of Claim of Exemption From Filing Certain Forms (see instructions)

10a Is this organization claiming exemption from filing Form 8872, Political Organization Report of Contributions and Expenditures, as a qualified
state or local political organization?
Yes
No
10b If “Yes,” list the state where the organization files reports
11 Is this organization claiming exemption from filing Form 990 (or 990-EZ), Return of Organization Exempt from Income Tax, as a caucus or
association of state or local officials?
Yes
No

Part III
12

Purpose

Describe the purpose of the organization

Part IV

List of All Related Entities (see instructions)

13

Check if the organization has no related entities

14a

Name of related entity

14b Relationship

䊳

14c Address

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

Cat. No. 30405V

Do not file a paper copy of Form 8871. File electronically only.

Form

8871

(Rev. 7-2003)

2
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8871, PAGE 2 of 4
MARGINS: TOP 13mm (1⁄2"), CENTER SIDES.
PRINTS: HEAD TO HEAD
PAPER: WHITE, WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 203mm (8") x 279mm (11")
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Do not file a paper copy of Form 8871. File electronically only.

Form 8871 (Rev. 7-2003)

Part V

Page

2

List of All Officers, Directors, and Highly Compensated Employees (see instructions)
15b Title

15c Address

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15a Name

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, and that I have examined this notice, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. I further declare that I am the official authorized to sign this report, and I am signing by entering my name
below.

Sign
Here

䊳

䊳

Name of authorized official

Printed on recycled paper

Do not file a paper copy of Form 8871. File electronically only.

Date

Form

8871

(Rev. 7-2003)