Certificate Of Exemption From Federal Excise Tax On Charges For Communication Services Form (Page 2 of 2) in pdf

CERTIFICATE OF EXEMPTION FROM FEDERAL EXCISE TAX

ON CHARGES FOR COMMUNICATION SERVICES (page 2)

(

) NONPROFIT EDUCATIONAL ORGANIZATION

The undersigned certifies that the communication services or facilities furnished or to be furnished to the organization will be paid from funds

of the organization and are for the exclusive use of the organization in the educational activities which qualify it for exemption from tax under

Section 4253 (j) of the Internal Revenue Code. The exempt organization normally maintains a regular faculty and curriculum, normally has a

regularly enrolled body of students in attendance at the place where its activities are regularly carried on, and has as its principal function

the providing of formal education.

The organization claiming exemption under this certificate has received a determination letter (or ruling) from the Internal Revenue Service

holding the organization to be exempt from income tax as an organization described in Section 501(c )(3) of the Internal Revenue Code (or

has received such determination letter (or ruling) under corresponding provisions for prior revenue laws) and the undersigned certifies that it

is an “educational organization” as described in Section 170(b)(1)(A)(ii) and the attendant regulations. The date of such determination letter

(or ruling) is _____________ and such determination letter (or ruling) has not been withdrawn or revoked.

Paid from the funds of: _________________________________

(

) NONPROFIT HOSPITAL

The undersigned has received a determination letter (or ruling) from the Internal Revenue Service holding the organization to be exempt

from income tax under Section 501(a) of the Internal Revenue Code (or has received such determination letter (or ruling) under

corresponding provisions for prior revenue laws) and the undersigned certifies that it is a “hospital” as described in Section 170(b)(1)(A)(iii)

and the attendant regulations. The date of such determination letter (or ruling) is _____________ and such determination letter (or ruling)

has not been withdrawn or revoked.

Paid from the funds of: _________________________________

The undersigned agrees to notify the providers of services in writing when the basis for tax exemption indicated above changes or ceases to

exist. The undersigned certifies that the exemption claimed is allowable under applicable laws and understands that the fraudulent use of

this certificate for the purpose of securing this exemption will subject each and all guilty parties to a fine of not more than $100,000

($500,000 for corporations) or to imprisonment for not more than five years or both, together with costs of prosecution (IRC Section 7201).

Exempt Organization

The Ohio State University

Federal ID Number:

31-6025986

Signature

Print Signature Name

Title

Date

_____________________________________________

(________)____________________________

Billing Name (as it appears on your billing statement)

Billing Telephone Number (include area code)

_____________________________________________

Billing Address: (as it appears on your billing statement)

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Certificate Of Exemption From Federal Excise Tax On Charges For Communication Services Form Page 2