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Form St-R-20 - Incorporated Nonprofit Organization For Fulfilling The Wishes Of Children With Life-Threatening Diseases

MAINE REVENUE SERVICES

SALES, FUEL & SPECIAL TAX DIVISION

EXEMPTION APPLICATION

INCORPORATED NONPROFIT ORGANIZATION FOR FULFILLING THE WISHES

OF CHILDREN WITH LIFE-THREATENING DISEASES

Name of Corporation _______________________________________________________

Name of Organization _______________________________________________________

Physical Location

_______________________________________________________

Mailing Address

_______________________________________________________

The statute reads, "Organizations fulfilling the wishes of children with life-threatening diseases.

Sales to incorporated nonprofit organizations whose sole purpose is to fulfill the wishes of

children with life-threatening diseases when their family or guardian is unable to otherwise

financially fulfill those wishes." PL 1989, c.502, Pt. A, §130 (new).

Is the organization incorporated? Yes ___ No ___

Has the organization 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 organization fulfilling the wishes of children with life-threatening

diseases. I therefore request that a sales/use tax exemption certificate be issued to the above

organization pursuant to Title 36 MRSA 1760 (63).

Date:

Signature: _____________________________

Tel:

Print Name: ____________________________

ID:

Title: _________________________________

Date Facility Opened: ____________________

ST-R-20 Rev 10/05

Phone: (207) 624-9693

TDD: (888) 577-6690

Fax: (207) 287-6628

E-mail: salestax@maine.gov

Form St-R-20 - Incorporated Nonprofit Organization For Fulfilling The Wishes Of Children With Life-Threatening Diseases