CITY OF LEEDS, ALABAMA
BUSINESS LICENSE TAX
SCHEDULE T - NOT-FOR-PROFIT AFFIDAVIT
1. Name of Organization: Date:
2. Address of Organization:
3. Form of Organization (i.e. corporation, partnership, LLC, etc.):
4. Classification (i.e. Public Charity, Private Foundation):
5. Date Exempt Status Granted:
6. Was the Organization required to file a Form 990-T (or other form used for reporting
unrelated business income) with the Internal Revenue Service for the previous tax year?
(Circle One) Yes No If yes, please attach a copy of Form 990-T (or other form) hereto.
I, ___________________________, the ______________________ of the Organization
named above, hereby affirm that the Organization is currently classified by the Internal Revenue
Service as tax-exempt under Section 501(c)(3) of the Internal Revenue Code of 1986, as
amended (“Section 501(c)(3)”). I further affirm that the Organization continues to operate in a
manner consistent with the requirements of Section 501(c)(3). A copy of the Internal Revenue
Service Determination Letter granted to the Organization dated __________________________
is attached hereto.
STATE OF ALABAMA )
COUNTY OF ____________ )
Before me, a Notary Public in and for said County and State, personally appeared
_____________________, the ________________________ of ________________________,
who acknowledged the execution of the foregoing, and who, having been duly sworn, stated that
the facts and matters set forth in it are true and correct.
Witness my hand and Notarial Seal this _____ day of _____________, 20___.
My Commission Expires Signature