Form St-R-37 - An Incorporated Nonprofit Dental Health Center (2005) printable pdf download

Form St-R-37 - An Incorporated Nonprofit Dental Health Center (2005)

MAINE REVENUE SERVICES

SALES, FUEL & SPECIAL TAX DIVISION

EXEMPTION APPLICATION

AN INCORPORATED NONPROFIT DENTAL HEALTH CENTER

Name of Corporation _______________________________________________________

Name of Dental Health Center_________________________________________________

Physical Location

_______________________________________________________

Mailing Address

_______________________________________________________

The statute reads, "incorporated nonprofit dental health centers,"

Is the dental health center incorporated? Yes ___ No ___

Has the dental health center received 501(c) nonprofit status from the IRS? Yes ___ No ___

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

Note: All information contained on this application is subject to VERIFICATION by Maine Revenue Services.

Maine Revenue Services may request additional information or documentation necessary to determine eligibility.

I hereby certify that ______________________________________________________ is an

incorporated nonprofit dental health center. 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-37 (Rev 10/05)

Phone: (207) 624-9693

TDD: (888) 577-6690

Fax: (207) 287-6628

E-mail: salestax@maine.gov

Form St-R-37 - An Incorporated Nonprofit Dental Health Center (2005)