Request Form For Extension Of Sales And Use Tax Exemption - Virginia Department Of Taxation Page 4

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SECTION D: SIGNATURES
This form must be completed with all required documentation attached, and timely filed in accordance
with Code of Virginia § 30-19.05.
WAIVER: The information provided in this request for Sales and Use Tax exemption shall NOT be
subject to the secrecy of information provisions of Code of Virginia §§ 30-28.18 or 58.1-3, or any other
secrecy of information provisions thereof, and shall become a part of the public legislative record.
However, this information may not be used for any purpose other than as part of the legislative record.
Signature of Delegate/Senator Sponsoring Exemption
________________________________________________________ Date _________________
Print Name of Delegate/Senator Sponsoring Exemption
_________________________________________________________________________________
The undersigned certifies that this organization’s financial records are true, accurate, and complete.
___________________________________________________ Date _________________
Business Authorized Representative*
*Required only if exemption applies to one business/organization
MAILING INFORMATION: Send completed form with attachments or change of address to:
Virginia Department of Taxation
Virginia Department of Taxation
Office of Customer Services
Office of Customer Services
Non-Profit ExemptionTeam
Or
Non-Profit Exemption Team
600 East Main Street
Post Office Box 546
Richmond, Virginia 23219
Richmond, Virginia 23218-0546
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