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Form Str-23 - Exemption Application Incorporated Nonprofit Corporation For The Purpose Of Conducting Medical Research

MAINE REVENUE SERVICES

SALES, FUEL & SPECIAL TAX DIVISION

EXEMPTION APPLICATION

INCORPORATED NONPROFIT CORPORATION FOR THE SOLE PURPOSE OF

CONDUCTING MEDICAL RESEARCH OR FOR THE PURPOSE OF

ESTABLISHING AND MAINTAINING LABORATORIES FOR SCIENTIFIC STUDY

AND INVESTIGATION IN THE FIELD OF BIOLOGY OR ECOLOGY OR

OPERATING EDUCATIONAL TELEVISION OR RADIO STATIONS

Name of Corporation _______________________________________________________

Name of Institution

_______________________________________________________

Physical Location

_______________________________________________________

Mailing Address

_______________________________________________________

The statute reads, "institutions incorporated as nonprofit corporations for the sole purpose of

conducting medical research or for the purpose of establishing and maintaining laboratories for

scientific study and investigations in the field of biology or ecology or operating educational

television or radio stations."

Is the institution incorporated? Yes ___ No ___

Has the institution 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

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 institution. 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: ______________________

STR-23 (Rev 10/05)

Phone: (207) 624-9693

TDD: (888) 577-6690

Fax: (207) 287-6628

E-mail: salestax@maine.gov

Form Str-23 - Exemption Application Incorporated Nonprofit Corporation For The Purpose Of Conducting Medical Research