Mfi Form St-5 - Medfield Foundation
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1
2Part 2. Agent information
To be completed
by agent of exem pt gollemment
or 501 (c)(3) organization.
Name
of agent's organization
Address
City
Agent's name
Address
City
I certify that in making this purchase, I am acting as ari agent for the exempt organization named above (select one):
D
Government organization (local public sChooi, city/town governinent,
state
agency, etc.).
.
Attach Form ST -2, if available, If Form
ST-2
is not available, enter exemption number, if known:
0
501 (c)(3) organization (parochial school, Scout troop, etc.). Form ST-2 must be attached.
signature
Vendor info
Part 3.
ation
rm
Signature
Check applicable box:
0
Single purchase certificate (attach detailed receipts or complete Part 4, on reverse)
0
Blanket certificate
.
This form is approved by the Commissioner of Revenue and may be reproduced.
2V2419
1.DDD
($50,000 for
~
State
Zip
~ ~
State
Zip
~
Titre
Date
~
TItle
Date
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