Form St-R-21 - Application For Sale/use Tax Exemption Certificate For An Incorporated Hospital
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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 HOSPITAL
Name of Corporation
_______________________________________________________
Name of Hospital
_______________________________________________________
Physical Location
_______________________________________________________
Mailing Address
_______________________________________________________
_______________________________________________________
_______________________________________________________
The statute reads, "Sales to incorporated hospitals,"
Is the hospital incorporated? Yes ___ No ___
Send a copy of the articles of incorporation
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 your license from the State of Maine Department of Behavioral and Developmental Services to
operate as a hospital
I hereby certify that ______________________________________________________ is an incorporated
hospital. 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:
Printed Name: ________________________________________
Fed ID:
Title: _______________________________________________
Date Facility Opened: __________________________________
ST-R-21
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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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