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

Form St-R-35 - Exemption Application Incorporated Nonprofit Rural Community Health Center Providing Different Facilities

MAINE REVENUE SERVICES

SALES, FUEL & SPECIAL TAX DIVISION

EXEMPTION APPLICATION

INCORPORATED NONPROFIT RURAL COMMUNITY HEALTH CENTER

ENGAGED IN,

OR PROVIDING FACILITIES FOR THE DELIVERY OF COMPREHENSIVE

PRIMARY HEALTH CARE

Name of Corporation

_______________________________________________________

Name of Health Center

_______________________________________________________

Physical Location

_______________________________________________________

Mailing Address

_______________________________________________________

The statute reads, "Sales to incorporated nonprofit home health care agencies certified under the

United States Social Security Act of 1965, Title XVIII, as amended, incorporated nonprofit rural

community health centers engaged in, or providing facilities for, the delivery of comprehensive

primary health care."

Is the rural community health center incorporated? Yes ___ No ___

Has the rural community health center 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 rural community health center. 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-35 (Rev 10/05)

Phone: (207) 624-9693

TDD: (888) 577-6690

Fax: (207) 287-6628

E-mail: salestax@maine.gov

Form St-R-35 - Exemption Application Incorporated Nonprofit Rural Community Health Center Providing Different Facilities