Form St-R-10 - Incorporated Nonprofrit Residential Care Facility printable pdf download

Form St-R-10 - Incorporated Nonprofrit Residential Care Facility

MAINE REVENUE SERVICES

SALES, FUEL & SPECIAL TAX DIVISION

EXEMPTION APPLICATION

( ) FOR AN INCORPORATED NONPROFIT RESIDENTIAL CARE FACILITY

( ) AN INCORPORATED NONPROFIT ASSISTED HOUSING PROGRAM FOR

THE ELDERLY

Name of Corporation _______________________________________________________

Name of Residential Care Facility ____________________________________________

Physical Location

_______________________________________________________

Mailing Address

_______________________________________________________

The statute reads, "Incorporated nonprofit residential care facilities and incorporated nonprofit

assisted housing programs for the elderly licensed by the Maine Department of Health and Human

Services,"

Is the residential care facility incorporated? Yes ___ No ___

Has the residential care facility 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. Copy of license issued by the Maine Department of Health and Human Services

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 residential care facility. 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-10 (Rev 10/05)

Phone: (207) 624-9693

TDD: (888) 577-6690

Fax: (207) 287-6628

E-mail: salestax@maine.gov

Form St-R-10 - Incorporated Nonprofrit Residential Care Facility