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Form 13909 Department of the Treasury-Internal Revenue Service (December2016) Tax-Exempt Organization Complaint (Referral) 1. Name of referred organization Street address City State ZIP code Date of referral 2. Organization' Employer Identification Number(EIN) 3. Nature of violation ❑ Directors/Officers/Persons are using income/assets for personal gain ❑ Organization is engaged in commercial, for-profit business activities ❑ Income/Assets are being used to support illegal or terrorist activities ❑ Organization is involved in a political campaign ❑ Organization is engaged in excessive lobbying activities ❑ Organization refused to disclose or provide a copy of Form 990 ❑ Organization failed to report employment, income or excise tax liability properly ❑ Organization failed to file required federal tax returns and forms ❑ Organization engaged in deceptive or improper fundraising practices ❑ Other(describe) 4. Details of violation Name(s)of person(s)involved Organizational title(s) Date(s) Dollar amount(s)(if known) Description of activities 5. Submitter information Name Occupation or business Street address City State ZIP code Telephone number ❑ I am concerned that I might face retaliation or retribution if my identity is disclosed 6.Submission and documentation: The completed form, along with any supporting documentation, may be mailed to IRS EO Classification, Mail Code 4910DAL, 1100 Commerce Street Dallas, TX 75242-1198, faxed to 214-413-5415 or emailed to eoclass&irs.gov. Disclaimer Notice:Your email submission of Form 13909 and attachments are not encrypted for security. Catalog Number 50614A www.irs.gov Form 13909 (Rev. 12-2016)