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

Form

8453-X

(Rev. October 2011)
Department of the Treasury
Internal Revenue Service

Part I

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

OMB No. 1545-1693

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

Part II

Sign
Here

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.

▲

▲

Signature of authorized official

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

Date

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. 10-2011)