Form R-1369a - Application For Certificate Of Authorization Exclusion For Purchases Of Bibles, Song Books, And Religious Instruction Literature


R-1369A (7/04)
Louisiana Department of Revenue
Application for Certificate of Authorization
Exclusion for Purchases of Bibles, Song Books,
and Religious Instruction Literature
Part 1 – Identification of Applicant
To be completed only by churches and synagogues that have been issued a letter of determination by the Internal Revenue Service as
entitled to exemption under Section 501(c)(3) of the United States Internal Revenue Code. A copy of the letter of determination must be
submitted with this form.
Please mark the box for the type of organization:
Independent Church
Association of Churches
(Attach a list with names and
locations of affiliated churches.)
1. Full name of organization
2a. Mailing address (number, street, and room or suite number)
2b. City or town, state, and ZIP
3a. Location address
3b. City or town, state, and ZIP
4a. Name of person to contact if additional information is needed
4b. Daytime telephone number
5. Federal Employer Identification Number (FEIN)
6. Louisiana General Sales/Use Tax Registration Number (if any)
Under the penalties of perjury, I declare that I am authorized to sign this application on behalf of the above organization and that
I have examined this application, and to the best of my knowledge it is true, correct, and complete.
Name of signer
Title or authority of signer
Part 2 – Activities and Operational Information
Please return the completed application to the following address:
Department of Revenue
Taxpayer Services Division
P.O. Box 3863
Baton Rouge, LA 70821-3863
Telephone: (225) 219-7356


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