Request Form For Extension Of Sales And Use Tax Exemption - Virginia Department Of Taxation Page 3

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SECTION C: BUSINESS/ORGANIZATION STRUCTURE
YOU MUST ATTACH THE RULING OR OTHER DOCUMENTATION TO INDICATE THAT THE
BUSINESS IS EXEMPT FROM FEDERAL INCOME TAX UNDER §501 (c) OF THE INTERNAL
REVENUE CODE.
1.
Describe the charitable purpose(s) for which the business/organization is organized and operated.
Include the charitable functions, business activities, and services provided to Virginia citizens. Attach
the Articles of Incorporation, Mission Statement, Statement of Purpose or any other appropriate
documentation.
2. Is more than 40 percent of the business/organization’s gross annual revenue, using generally accepted
accounting principles, spent on general administration, including salaries, and fund raising?
YES ______NO______
(Attach a financial statement or other proof to verify the 40 percent cost.)
3. List the address, if different from the physical address, where the business/organization’s financial
records are available for public inspection.
Street: _________________________________________________________________
City ________________________________ State ___________ ZIP_______________
4. List the salaries, including ALL benefits, for the five employees of the business/organization that
receive the highest compensation. You do not have to provide the names of the
employees.
A. _______________________________
B. _______________________________
C. _______________________________
D. _______________________________
E. _______________________________
5. Is the business/organization’s gross annual revenue $250,000 or greater? YES___ NO____
If YES, you MUST attach the most recent financial audit that was performed by an independent
Certified Public Accountant.
6. Is the business/organization subject to Chapter 5 (§ 57-48 et seq.) of Title 57 of the Code of Virginia,
relating to solicitation of contributions? YES ____ NO_____
If YES, provide proof of compliance with this chapter. (Proof of compliance includes documentation
that reflects registration with the Virginia Department of Agriculture and Consumer Services.
Charitable organizations, that intend to solicit contributions within the Commonwealth, may be
required to register. (Please call 804-371-0392 for information)
7. Does the business/organization have a volunteer Board of Directors? YES_____ NO_____
If YES, list the names and home addresses of the Directors below.
NAME
ADDRESS
________________________________________
______________________________
______________________________
________________________________________
______________________________
______________________________
________________________________________
______________________________
______________________________
________________________________________
______________________________
______________________________
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