Form St-119.2-I - 2013 - Application For An Exempt Organization Certificate Page 3

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ST-119.2

New York State and Local Sales and Use Tax

Application for an Exempt

(9/11)

Organization Certificate

State and Local Sales and Use Tax

Name of organization

Organization’s telephone number

(

)

Physical address

City

State

ZIP code

(number and street)

Mailing address

City

State

ZIP code

Name and title of person to be contacted

Contact person’s telephone number

(see instructions)

(

)

Email address of person to be contacted

Contact person’s fax number

(

)

Date formally organized

Date incorporated

Federal employer identification number

Mark an X in the appropriate box to indicate the Tax Law section under which you are claiming exempt status.

Section 1116(a)(4) – Mark an X in the appropriate box to indicate the purpose for which you are claiming exempt status

(see instructions).

Religious

Testing for public safety

Prevention of cruelty to children or animals

Charitable

Scientific

Fostering national or international amateur sports competition

Educational

Literary

Section 1116(a)(5) – A post or organization organized in New York State of past or present members of the United States

armed forces, or an auxiliary unit or society of, or a trust or foundation for, any such post or organization organized in

New York State (see instructions).

What percentage of your members are past or present members of the United States armed forces? ........

What percentage of your members are cadets or are spouses, widows, widowers, ancestors, or lineal

descendants of past or present members of the United States armed forces or of cadets? ......................

What percentage of your members do not fall within either of the above categories? ...................................

If the post or organization has received a federal ruling on its exemption claim, attach a copy of the federal determination

letter confirming your Internal Revenue Code (IRC) section 501(c)(19) exemption.

Section 1116(a)(7) – A not-for-profit corporation acting as a health maintenance organization subject to the provisions of

Public Health Law Article 44. You must attach a copy of the certificate of authority issued by the New York State Health Department.

Section 1116(a)(8) – A cooperative or foreign corporation doing business in this state pursuant to the Rural Electric

Cooperative Law.

Section 1116(a)(9) – A credit union, as defined by New York State Banking Law section 2(9), where it is the

purchaser, user, or consumer of services or property, or where it is a vendor of services or property of a kind not ordinarily

sold by private persons (see instructions).

2 Are you currently registered for sales tax purposes with the Tax Department? ................................................. Yes

If Yes, enter your sales tax Certificate of Authority number

If you answer Yes to questions 3 through 7, attach an explanation (see instructions).

3 Has any distribution of the organization’s property ever been made to shareholders, members, or other

individuals? ...................................................................................................................................................... Yes

4 Does any part of the net earnings of the organization go to the benefit of any private shareholder or individual? .... Yes

5 If you marked box 1a, has the organization ever attempted to influence legislation? ........................................ Yes