Looking for a Maine Legal Forms And Templates? Download it for free!

Form St-R-43 - Exemption Application Incorporated Nonprofit Organization Or Their Affiliates Whose Purpose Is To Provide Free Clinical Assistance

MAINE REVENUE SERVICES

SALES, FUEL & SPECIAL TAX DIVISION

EXEMPTION APPLICATION

INCORPORATED NONPROFIT ORGANIZATION OR THEIR AFFILIATES WHOSE

PURPOSE IS TO PROVIDE FREE CLINICAL ASSISTANCE TO CHILDREN WITH

DYSLEXIA

Name of Corporation_______________________________________________________

Name of Organization______________________________________________________

Physical Location

_______________________________________________________

Mailing Address

_______________________________________________________

The statute reads, "Incorporated nonprofit organization or their affiliates whose purpose is to

provide free clinical assistance to children with dyslexia."

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. 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-43 (Rev 10/05)

Phone: (207) 624-9693

TDD: (888) 577-6690

Fax: (207) 287-6628

E-mail: salestax@maine.gov

Form St-R-43 - Exemption Application Incorporated Nonprofit Organization Or Their Affiliates Whose Purpose Is To Provide Free Clinical Assistance