PS Form 3624 - Application to Mail at Nonprofit USPS Marketing

11. Is this organization exempt from federal income tax? (If

‘Yes,’ attach a copy of the exemption issued by the Internal

Revenue Service (IRS) that shows the section of the IRS

code under which the organization is exempt. Required if

exempt. Do not submit State tax exemption information.)

Has the IRS denied or revoked the organization’s federal tax

exempt status? (If `Yes,’ attach a copy of the IRS ruling to

this PS Form 3624.)

 The applicant named in item 7 must be the individual submitting the application for

the organization and must be a responsible official of the organization. Printers and

mailing agents may not sign for the organization.

 No additional organization categories may be added in item 9. To be eligible for the

Nonprofit USPS Marketing Mail prices, the organization must qualify as one of the

types listed.

 The applicant must sign the application in item 15.

 The application must be submitted to the Post Office in item 14 and on the date

shown in item 17.

Application to Mail at

Nonprofit USPS Marketing Mail Prices

Part 1 (For completion by applicant)

Section A - Application (Please read section B on page 2 before completion.)

Application Number:

PS Form 3624, January 2017 (Page 1 of 3) PSN 7530-02-000-9014

Part 2 (For completion by postmaster at originating office when application filed)

1. Signature of Postmaster (Or designated representative)

2. Date Application Filed With Post Office (Round stamp)

I certify that the statements made by me are true and complete. I understand

that anyone who furnishes false or misleading information on this form or

who omits material information requested on the form may be subject to

criminal sanctions (including fines and imprisonment) and/or civil sanctions

(including multiple damages and civil penalties). I further understand that, if this

application is approved, a postage refund

for the difference between the regular

USPS Marketing Mail and Nonprofit USPS Marketing Mail prices may be made

for only mailings entered at regular USPS Marketing Mail prices at the Post Office

identified above while this application is pending, provided that the conditions set forth

in Domestic Mail Manual 703.1 and 703.1.9 are met.

15. Signature of Applicant

17. Date

16. Title

 All information entered below must be legible so that our records

will show the correct information about your organization.

 The complete name of the organization must be shown in item 1.

The name shown must agree with the name that appears on all

documents submitted to support this application.

 A complete address representing a physical location for the

organization must be shown in item 2. If you receive mail through a

Post Office™ box, show your street address first and use alternate

address for the box.

Yes

14. Post Office (not a station or branch) where authorization requested

and bulk mailings will be made (City, state, ZIP Code™).

(10) Voting registration official

(Go to item 12)

Yes

12. Has this organization previously mailed at the Nonprofit USPS

Marketing Mail prices? (If `Yes,’ list the Post Office locations

where mailings were most recently deposited at these prices

and provide the nonprofit authorization number, if known.)

Yes

13. Has your organization had Nonprofit USPS Marketing Mail

privileges denied or revoked? (If `Yes,’ list the Post Office (city

and state) where the application was denied or authorization

was revoked and provide the nonprofit authorization number, if

known.)

10. Is this a for-profit organization or does any of the net income

inure to the benefit of any private stockholder or individual?

(09) Qualified political committee

(Go to item 12)

(08) Fraternal

(07) Veterans(05) Agricultural

(06) Labor(04) Philanthropic

(03) Scientific

(02) Educational

(01) Religious

9. Type of Organization (Check only one)

7. Name of Applicant (Must represent applying organization)6. Telephone (Include area code)

8. Email Address

3. City, State, ZIP+4

Code

2. Street Address of Organization (Include apartment or suite number)

1. Complete Name of Organization (If voting registration official, include title)

No application fee is required. (All information must be complete and typewritten or printed legibly.)

Not all nonprofit organizations are eligible for the Nonprofit USPS Marketing Mail prices. Domestic Mail Manual® 703.1 lists certain organizations (such

as business leagues, chambers of commerce, civic improvement associations, social and hobby clubs, governmental bodies, and others) that, although

nonprofit, do not qualify for the Nonprofit USPS Marketing Mail prices.

From your IRS exemption letter, check off the box corresponding

to the section under which the organization is exempt:

501(c)(3)

501(c)(8) 501(c)(19)

501(c)(5)

Other 501(c) ( ) (See statement in item 9 above)

PRIVACY NOTICE: See our privacy policy on www.usps.com

4. Alternate Mailing Address

5. Alternate City, State, ZIP+4

Code

Section B—General Information

Organization Eligibility

The Nonprofit USPS Marketing Mail

prices may be granted only to:

1. The eight categories (01 through 08) of nonprofit organizations specified on page 1 in section A, item 9.

2. Qualified political committees (category 09), including the national and state committees of political parties as

well as certain named congressional committees.

3. Voting registration officials (category 10), including local, state, and District of Columbia voting registration

officials.

These organizations are defined in Domestic Mail Manual (DMM

) 703.1, available for review at pe.usps.com.

To qualify, a nonprofit organization must be both organized and operated for a primary purpose that is consistent with

one of the types of organizations in DMM 703.1. Organizations that incidentally engage in qualifying activities do not

qualify for the Nonprofit USPS Marketing Mail prices.

Mail Eligibility

An organization authorized to mail at the Nonprofit USPS Marketing Mail prices may mail only its own matter at those

prices. It may not delegate or lend the use of its Nonprofit USPS Marketing Mail authorization to any other person

or organization. Cooperative mailings may be made at the Nonprofit USPS Marketing Mail prices only if each of the

cooperating organizations is individually authorized to mail at those prices.

DMM 703.1 discusses the specific restrictions against the mailing of certain advertising materials and products.

PS Form 3624, January 2017 (Page 2 of 3)

Supporting Documentation

The documents listed in 1 and 2 below must be submitted with the completed applications for nonprofit organizations.

The documents listed in 3 must be submitted for qualified political committees and, in 4, for voting registration officials.

1. Evidence that the organization is nonprofit and that none of its net income inures to the benefit of any private

stockholder or individual. Acceptable evidence includes:

  An Internal Revenue Service (IRS) letter of exemption from payment of federal income tax.

  If an IRS exemption letter is not available, a complete financial statement from an independent auditor (such as a

certified public accountant) substantiating that the organization is nonprofit. A statement from a member of the

organization is not sufficient. (Do not submit State tax exemption information.)

2. Documents describing the organization’s primary purpose, such as:

  Organizing instruments that state the purpose for which the group is organized, such as the constitution, articles

of incorporation, articles of association, or trust indenture. The organizing instrument, including all amendments

to the original, should bear the seal, certification, or signature of the Secretary of State or other appropriate state

official. If one or more of these documents are not sealed, certified, or signed by state officials, an officer or

other person authorized to sign for the applicant should submit a written declaration certifying that the

documents are complete and accurate copies of the originals.

  Materials showing how the organization actually operated during the previous 6 to 12 months and how it will

operate in the future. Bulletins, financial statements, membership forms, publications produced by the

organization, minutes of meetings, or a list of its activities may be used.

3. For qualified political committees (category 09), organizational or other documents substantiating that the applicant is

the state or national committee of the political party.

4. For voting registration officials (category 10), a copy of the statute, ordinance, or other authority establishing

responsibility for voter registration.

Application Procedures

1. Only organizations may apply. Individuals may not apply (except voting registration officials).

2. Only the one category in item 9 that best describes the primary purpose of the organization may be checked.

3. The application must be signed by someone in authority in the organization, such as the president or treasurer. It

must not be signed by a printer or mailing agent.

4. The completed PS Form 3624 must be submitted to the Post Office where Nonprofit USPS Marketing Mail mailings

will be deposited. If the application is approved, the authorization will apply nationwide. Use PS Form 3623,

Request for Confirmation of Authorization (or Pending Application) to Mail at Nonprofit USPS Marketing Mail

Prices, to deposit at a Post Office location that does participate in PostalOne!.

Postal Service™ Checklist for PS Form 3624,

Application to Mail at Nonprofit USPS Marketing Mail

Prices

Name of Organization

The organization above provided the following evidence of eligibility for Nonprofit USPS Marketing Mail prices.

1. Nonprofit Status (Select at least one)

2. Organization (One complete copy; check all that apply. Must select at least one.)

3. Operation (Several samples of each; check types of information included with application)

The name on all the documents presented as evidence must match the name on the application. If they do not match, please explain.

I certify that the applicant has completed all the items on the application and that each item is legible.

Signature of Postmaster (Or designated representative)

Telephone (Include area code) Post Office (City, state, ZIP Code™)

Date Application Returned to Organization for Correction Date Application and Documentation Sent to Pricing and Classification

Service Center

IRS letter of exemption from payment of federal income tax

Financial statement prepared by an independent auditor substantiating organization’s nonprofit status (statement must include balance

sheets, notes, etc.)

Place of Worship

Articles of Incorporation Articles of Association ConstitutionCharter

Bulletins

Newsletters

Financial statements

Minutes of meetings

Brochures

Membership applications

Organizational or other documents substantiating that the applicant is the state or national committee of the political party

A copy of the statute, ordinance or other authority establishing responsibility for voter registration

Listing of activities for past 6 to

12 months

Other (Explain):

PS Form 3624, January 2017 (Page 3 of 3) PSN 7530-02-000-9014

Date

Postmaster: PostalOne! offices must enter the information from the application into the PostalOne! system.

Non-PostalOne! offices must mail the application and documentation to the Pricing and Classification Service Center.

PRIVACY NOTICE: See our privacy policy on www.usps.com

Other (Explain):

Trust IndentureEnabling Legislation