Form Str-28 - Application For Sale/use Tax Exemption Certificate For An Incorporated Nonprofit Hospice Organization
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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 HOSPICE ORGANIZATION
Name of Corporation
_______________________________________________________
Name of Hospice Organization_______________________________________________________
Physical Location
_______________________________________________________
Mailing Address
_______________________________________________________
_______________________________________________________
_______________________________________________________
The statute reads, "Incorporated nonprofit hospice organizations. Sales to incorporated nonprofit hospice
organizations which provide a program or care for the physical and emotional needs of terminally ill patients. PL
1985, c. 788, §1 (new)."
Is the hospice organization incorporated? Yes ___ No ___
Send a copy of the articles of incorporation
Has the hospice 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
I hereby certify that ______________________________________________________ is an incorporated
nonprofit hospice organization. I therefore request that a sales/use tax exemption certificate be issued to the
above organization pursuant to Title 36 MRSA 1760 (55).
Date:
Signature: ___________________________________________
Tel:
Print Name: __________________________________________
Fed. ID: ______________________
Title: _______________________________________________
Fed ID:
Date Facility Opened: __________________________________
STR-28
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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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