Form St-Nh-1 - Application For Registration And Certificate Of Exemption Number For Licensed Nursing Homes, Licensed In-Patient Hospices, General Hospitals, Mental Hospitals
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1ST-NH-1 (REV. 02/02)
Department of Revenue
Sales and Use Tax Division
1800 Century Center Boulevard, NE, Ste. 15311
Clear Form
Atlanta, Georgia 30345-3205
Telephone: (404) 417-6649
APPLICATION FOR REGISTRATION AND CERTIFICATE OF EXEMPTION NUMBER FOR LICENSED
NURSING HOMES, LICENSED IN-PATIENT HOSPICES, GENERAL HOSPITALS, MENTAL HOSPITALS
EVERY QUESTION MUST BE ANSWERED IN FULL (Please print or type)
_______________________________________________________________________________________________________________________________________
(NAME OF INSTITUTION)
(PHONE NUMBER)
________________________________________________________________________________________________________________________________________________________________________________________________________________________
(MAILING ADDRESS)
________________________________________________________________________________________________________________________________________________________________________________________________________________________
(LOCATION ADDRESS)
Type of Ownership:
[ ] Individual
[ ] Corporation
[ ] Partnership
[ ] Authority
[ ] Other (Explain) _____________________________________
Date on which the institution was first operated:______________________
Type of Operation:
[ ] Licensed
[ ] Licensed
[ ] Licensed
[ ] Licensed
Nonprofit
Nonprofit
Nonprofit
Nonprofit
Nursing Home
Inpatient Hospice
General Hospital
Mental Hospital
Do you make sales to persons other than patients who are confined at such institution? [ ] Yes. [ ] No. If yes, indicate below
the tangible personal property sold. (For example: meals, drugs, hospital supplies, flowers, gifts, periodicals, etc.)
________________________________________________________________________________________________________________________________________________________________________________________________________________________
(TANGIBLE PERSONAL PROPERTY SOLD)
Are you now registered as a dealer with this Division? [ ] Yes. [ ] No. __________________________________
(GA SALES/USE TAX CERTIFICATE OF REGISTRATION NO.)
If no, have you filed an application? [ ] Yes. [ ] No.
________________________________________________________________________________________________________________________________________________________________________________________________________________________
(OWNER OF EQUIPMENT USED IN THE OPERATION OF THIS INSTITUTION)
Is this institution licensed as a nonprofit entity by the Georgia Department of Human Resources? [ ] Yes. [ ] No. If yes, attach
a copy of the institution’s license and “Policy of Admission” as adopted by your Board of Directors or Governors.
Is this institution operating under a nonprofit charter approved by the Internal Revenue Service? [ ] Yes. [ ] No. If yes, attach a
copy of the Internal Revenue Service’s letter of determination.
_______________________________________________________________________________________________________
I certify that this application has been examined by me and to the best of my knowledge is true and correct.
_______________________________________________________________________________________________________
(TITLE)
(MM/DD/YY)
(SIGNATURE AND TITLE)
(DATE SIGNED)
APPROVED BY:
_______________________________________________________________________________________________________
DEPARTMENT OF REVENUE
(DATE APPROVED)
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