Form St-R-31 - Incorporated Nonprofit Nursing Home printable pdf download

Form St-R-31 - Incorporated Nonprofit Nursing Home

MAINE REVENUE SERVICES

SALES, FUEL & SPECIAL TAX DIVISION

EXEMPTION APPLICATION

INCORPORATED NONPROFIT NURSING HOME

Name of Corporation _______________________________________________________

Name of Nursing Home _______________________________________________________

Physical Location

_______________________________________________________

Mailing Address

_______________________________________________________

“The statute reads, incorporated nonprofit nursing homes licensed by the Maine Department of

Health and Human Services "

Is the nursing home incorporated? Yes ___ No __

Is the nursing home licensed by the Maine Department of Health and Human Services?

Yes___ No ___

Has the nursing home 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 nursing home license from the Maine Department of Health and Human Services.

3. 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 nursing home licensed by the Maine Department of Health and Human Services. 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-31 (Rev 10/05)

Phone: (207) 624-9693

TDD: (888) 577-6690

Fax: (207) 287-6628

E-mail: salestax@maine.gov

Form St-R-31 - Incorporated Nonprofit Nursing Home