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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.

Signature

Name of signer

Date

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

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