Form St-R-43 - Application For Sale/use Tax Exemption Certificate For An Incorporated Nonprofit Organization Or Their Affiliates Whose Purpose Is To Provide Free Clinical Assistance To Children With Dyslexia
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1S T A T E O F M A I N E
M A I N E R E V E N U E S E R V I C E S
ADMINISTRATIVE & FINANCIAL
2 4
S T A T E H O U S E S T A T I O N
SERVICE
,
A U G U S T A
M A I N E
REBECCA M. WYKE
0 4 3 3 3 - 0 0 24
COMMISSIONER
John Elias Baldacci
JEROME D. GERARD
GOVERNOR
ACTONG EXECTUTIVE DIRECTOR
APPLICATION FOR SALE/USE TAX EXEMPTION CERTIFICATE
FOR AN INCORPORATED NONPROFIT ORGANIZATION OR THEIR AFFILIATES WHOSE
PURPOSE IS TO PROVIDE FREE CLINICAL ASSISTANCE TO CHILDREN WITH DYSLEXIA
Name of Corporation
_______________________________________________________
Name of Organization
_______________________________________________________
Physical Location
_______________________________________________________
_______________________________________________________
Mailing Address
_______________________________________________________
_______________________________________________________
_______________________________________________________
The statute reads, "Incorporated nonprofit organization or their affiliates whose purpose is to provide free
clinical assistance to children with dyslexia."
Is the organization incorporated? Yes ___ No ___
Send a copy of the articles of incorporation
Has the organization received 501(c) nonprofit status from the IRS? Yes ___ No ___
Send a copy of the IRS determination letter indicating 501(c) nonprofit status
IN ORDER TO PROCESS THE APPLICATION THE FOLLOWING MUST BE INCLUDED
1. Copy of the Articles of Incorporation, as well as a copy of the Constitution and/or By-law
2. Copy of the IRS determination letter indicating 501(c) nonprofit status
3. Please forward any publications issued by your organization which would provide details regarding purpose,
mission and/or services offered, if applicable.
I hereby certify that ______________________________________________________ is an incorporated
nonprofit organization. I therefore request that a sales/use tax exemption certificate be issued to the above
organization pursuant to Title 36 MRSA 1760 (16).
Date:
Signature: ___________________________________________
Tel:
Print Name: _________________________________________
Fed ID:
Title: _______________________________________________
Date Facility Opened: __________________________________
ST-R-43
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E A R I N G
M P A I R E D
H O N E
E-mail:
sales.tax@state.me.us
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