Form
8453-X
(Rev. August 2013)
Department of the Treasury
Internal Revenue Service
Political Organization Declaration for Electronic Filing
of Notice of Section 527 Status
Information about Form 8453-X and its instructions is at www.irs.gov/form8453.
OMB No. 1545-1693
Part I
Notice Information
1 Name of organization Employer identification number
2 Mailing address (P.O. box or number, street, and room or suite number)
City or town, state, and ZIP code
3 Confirmation number
4a Date Form 8871 filed 4b Time Form 8871 filed
Part II
Declaration
Sign
Here
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.
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. 8-2013)
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signature
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