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. 
 
       Signature:      
       Print Name:       
                                               Position:                                    
 
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      
Resident of                    County          Printed                                      
           Notary Public