Form St-R-42 - Incorporated Nonprofit Statewide Orgnization printable pdf download

Form St-R-42 - Incorporated Nonprofit Statewide Orgnization

MAINE REVENUE SERVICES

SALES, FUEL & SPECIAL TAX DIVISION

EXEMPTION APPLICATION

INCORPORATED NONPROFIT STATEWIDE ORGANIZATION THAT ADVOCATE

FOR CHILDREN AND THAT ARE MEMBERS OF THE MEDICAID ADVISORY

COMMITTEE

Name of Corporation ______________________________________________________

Name of Organization ______________________________________________________

Physical Location

______________________________________________________

Mailing Address

______________________________________________________

The statute reads, "Statewide organizations that advocate for children and that are members of

the Medicaid Advisory Committee."

Is the organization incorporated? Yes ___ No __

Send a copy of the articles of incorporation

Has the 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

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 under the pains and penalties of perjury that _____________________________________________________

is an incorporated non profit organization that advocate for children and are members of the Maine Care Advisory Committee.

therefore request that a sales/use tax exemption certificate be issued to the above organization pursuant to Title 36

)

MRSA 1760 (49

Date:

Signature:_______________________________

Tel:

Print Name: _____________________________

Fed ID# _______________________

Title: __________________________________

Date Facility Opened: ____________________

ST-R-42 (Rev 10/05)

Phone: (207) 624-9693

TDD: (888) 577-6690

Fax: (207) 287-6628

E-mail: salestax@maine.gov

Form St-R-42 - Incorporated Nonprofit Statewide Orgnization