Form  8453-X                Political Organization Declaration for Electronic Filing    
(Rev. August 2013)                                  of Notice of Section 527 Status                               OMB No. 1545-1693
Department of the Treasury  
Internal Revenue Service    ▶ Information about Form 8453-X and its instructions is at www.irs.gov/form8453.
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 

             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 
Sign         complete. 
Here 
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                   Signature of authorized official                                                               Date 
Instructions                                                                 Upon receipt of this form, the Internal Revenue Service  
                                                                             will send the organization a username and password that 
After electronically submitting Form 8871, an                                must be used to file an amended or final Form 8871 or to 
authorized official must sign, date, and send Form                           electronically file Form 8872, Political Organization 
8453-X to:                                                                   Report of Contributions and Expenditures. 
                   Department of the Treasury   
                   Internal Revenue Service   
                   Ogden, UT 84201 

For Paperwork Reduction Act Notice, see separate Instructions for Form 8871.           Cat. No. 36512T      Form  8453-X (Rev. 8-2013)