Form 21919 - Application For Sales Tax Exemption Certificate

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North Dakota

Ofﬁ ce Use Only

Application For Sales Tax Exemption

Certiﬁ cate

Ofﬁ ce of State Tax Commissioner

See the Exempt Organizations guideline for more detail

Sales & Special Taxes

600 E. Boulevard Ave., Dept. 127

about organizations that qualify for a sales tax exemption on

Bismarck, ND 58505-0599

purchase transactions.

This application should be ﬁ led only by federal, state, or local governments; federal corporations; schools; hospitals, nursing homes,

intermediate care facilities, basic care facilities, and emergency medical service providers licensed by the State Department of Health;

voluntary health associations recognized by the National Health Council; and assisted living facilities licensed by the Department of

Human Services.

Name of Organization

Name

Federal Identiﬁ cation Number (FEIN)

Phone Number

Street Address

City

State

Zip Code

Location

PO Box or Street Address

City

State

Zip Code

Mailing Address

(If Different From

Above)

 Federal Government



State

County or Township

City



Public or Private School, College or University

Voluntary Health Association

Type of



Intermediate Care Facility (ND Department of Health license no. _______________)



Organization

Assisted Living Facility (ND Human Services license no. _______________)



Basic Care Facility (ND Department of Health license no. _______________)

(Check One)



Emergency Medical Services Provider (ND Department of Health license no. _______________)



Hospital (ND Department of Health license no. _______________)



Skilled Nursing Facility (ND Department of Health license no. _______________)

Provide explanation of primary function of organization _______________________________

_______________________________________________________________________________



(1) Does the organization hold a sales and use tax permit?

Yes



(2) Does the organization make any retail sales?

Yes

Authorized Purchasing Agent ________________________________________________________________________________

Name

Title

Phone Number

I certify that the above statements are correct to the best of my knowledge and belief and that I am authorized to sign this

application.

Signed _________________________________________

Title ________________________________________

Print Name ______________________________________

Date ________________________________________

IMPORTANT: The Certiﬁ cate of Exemption, if granted, applies to purchases only. It does not apply to the sale of tangible personal property. As soon as your

application is approved, a Certiﬁ cate will be mailed. This certiﬁ cate must be retained by you and a copy of your certiﬁ cate must be furnished to all suppliers or

retailers at the time of purchase.

Phone: 701-328-1246

E-mail:

salestax@nd.gov

21919

Fax:

701-328-0336

Web site:

(Rev. 6/05)