Florida Department Of Revenue Forms Application For Consumer'S Certificate Of Exemption Page 4

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Application for Consumer’s Certificate of Exemption

R. 11/03

Sales and Use Tax [pursuant to ss. 212.08(6), (7), and 213.12(2), Florida Statutes]

* NO FEE REQUIRED *

CHECK ONE:

New

Renewal

Certificate No.

MAIL TO:

ACCOUNT MANAGEMENT/EXEMPTIONS

FLORIDA DEPARTMENT OF REVENUE

PO BOX 6480

TALLAHASSEE FL 32314-6480

Exemption category for which you are applying (check only one):

501 (c)(3) Organization

Organization Benefiting Minors

Office Use Only

Community Cemetery

Parent-Teacher Organization/Association

BP _____________________

Credit Union

Political Subdivision

Fair Association

Religious - physical place of worship

CO _____________________

Florida Fire and Emergency Services Foundation

Religious - governing/administrative

RS _________ N ___ R ____

Florida Retired Educators Association

Religious - transportation provider

Library Cooperative

School, College or University

PM Date ________________

Nonprofit Cooperative Hospital Laundry

Veterans' Organization

Date Rec'd ______________

Nonprofit Water System

Volunteer Fire Department

Organization Name

Business Phone

Street Address

State

ZIP

City

County, if located in Florida

Date of Incorporation

Federal Employer Identification Number (FEIN)

Does organization hold IRS exempt status?

Is Organization incorporated?

Yes

Alternate Phone

Mailing Address (If different than above)

State

ZIP

City

County, if located in Florida

Yes

Does the organization receive income from the sale or lease of tangible personal property, the lease of real property or the sale of taxable services?

If yes, provide the organization’s sales and use tax certificate of registration number:

ALL DOCUMENTS SUBMITTED WILL BE RETAINED AS PART OF THIS APPLICATION.

CERTIFICATION

I hereby attest that I am authorized to sign on behalf of the applicant organization described above. I further attest that, if granted, the

Consumer's Certificate of Exemption will only be used in the manner authorized for this organization under ss. 212.08(6), (7), or 213.12(2),

Florida Statutes.

I declare that I have read the information provided on this application, including the attached documentation, and that the facts stated

herein are true.

Signature

Title

Print Name

Date