Form St-Nh-1 - Application For Certification Of Exemption Licensed Nonprofit In-Patient: Nursing Home, Hospice, General Hospital Or Mental Hospital

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ST-NH-1 (rev. 06/2014)
Department of Revenue
Legal Affairs & Tax Policy
1800 Century Blvd. N.E. STE 15107
Atlanta, GA 30345
(404) 417-6649
Application for Certification of Exemption
Licensed Nonprofit In-patient: Nursing Home, Hospice, General Hospital or Mental Hospital
O.C.G.A. § 48-8-3(7); Ga. Comp. R. & Regs r. 560-12-2-.92
(Please Print)
NAME OF INSTITUTION
INSTITUTION REPRESENTATIVE CONTACT NAME AND PHONE NUMBER
MAILING ADDRESS
LOCATION ADDRESS
□
□
□
□
Type of Operation:
State
State
State
State
Licensed
Licensed
Licensed
Licensed
Nonprofit
Nonprofit
Nonprofit
Nonprofit
Nursing Home
Inpatient Hospice
General Hospitals
Mental Hospital
Federal Employer Identification Number (FEIN):
The following documents must be submitted with this completed application:
A copy of the applicant’s 501(c)(3) Determination Letter issued by the Internal Revenue Service (IRS).
A copy of applicant’s license issued by appropriate Georgia regulatory body.
Under penalties of perjury, I certify that this application has been examined by me and to the best of my
knowledge is true and correct.
Signature
Date
Printed Name
Title

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