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Form St-R-25 - Exemption Application An Incorporated Nonprofit Organization That Loans Medical Supplies And Equipment To Persons

MAINE REVENUE SERVICES

SALES, FUEL & SPECIAL TAX DIVISION

EXEMPTION APPLICATION

AN INCORPORATED INTERNATIONAL NONPROFIT ORGANIZATION THAT

LOANS MEDICAL SUPPLIES AND EQUIPMENT TO PERSONS

Name of Corporation _____________________________________________________

Name of Organization

Physical Location

______________________________________________________

Mailing Address

______________________________________________________

_______________________________________________________

The statute reads, "Charitable suppliers of medical equipment. Sales to local branches of

incorporated international nonprofit charitable organizations which provide, on a loan basis and

free of charge, medical supplies and equipment to persons. PL 1989, c. 502, Pt. A, §129 (rpr)."

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

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 international nonprofit organization. I therefore request that a sales/use tax

exemption certificate be issued to the above organization pursuant to Title 36 MRSA 1760 (62).

Date:

Signature:______________________________

Tel:

Print Name:_____________________________

Fed ID# _______________________

Title: __________________________________

Date Facility Opened:______________________

ST-R-25 (Rev 10/05)

Phone: (207) 624-9693

TDD: (888) 577-6690

Fax: (207) 287-6628

E-mail: salestax@maine.gov

Form St-R-25 - Exemption Application An Incorporated Nonprofit Organization That Loans Medical Supplies And Equipment To Persons