Form St-R-32 - Incorporated Nonprofit Home Health Care Agency printable pdf download

Form St-R-32 - Incorporated Nonprofit Home Health Care Agency

MAINE REVENUE SERVICES

SALES, FUEL & SPECIAL TAX DIVISION

EXEMPTION APPLICATION

INCORPORATED NONPROFIT HOME HEALTH CARE AGENCY

Name of Corporation_______________________________________________________

Name of Home Health Care Agency __________________________________________

Physical Location __________________________________________________________

Mailing Address __________________________________________________________

__________________________________________________________

The statute reads, "Incorporated nonprofit home health care agencies certified under the United

States Social Security Act of 1965, Title XVIII, as amended."

Is the home health care agency incorporated? Yes ___ No ___

Has the home health care agency 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. Copies of any licenses in reference to this agency.

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 nonprofit home health care agency. 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-32 (Rev 10/05)

Phone: (207) 624-9693

TDD: (888) 577-6690

Fax: (207) 287-6628

E-mail: salestax@maine.gov

Form St-R-32 - Incorporated Nonprofit Home Health Care Agency