Form 8274 Rev August 2014 Information about Form 8274 and its instructions is at wwwirsgovform8274 File Two Copies Please type or print Full name of organization Employer identification nu ID: 495852
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Form 8274 (Rev. August 2014) Department of the Treasury Internal Revenue Service Certification by Churches and Qualified Church- Controlled Organizations Electing Exemption From Employer Social Security and Medicare Taxes Information about Form 8274 and its instructions is at www.irs.gov/form8274. File Two Copies Please type or print Full name of organization Employer identification number (EIN) Address (number and street or P.O. box number if mail is not delivered to street address) City, state, and ZIP code Date wages first paid If exemption is based on a group ruling, give full name of central organization Group exemption number Sign Here (Signature of authorized official) (Title) (Date) Purpose of form. Churches and qualified church-controlled organizations (defined below) that are opposed, for religious Cat. No. 61933Q Form 8274 (Rev. 8-2014)