Form St: Ex-A3 - Application For State Utility/mobile Communication Services Tax Certificate Of Exemption

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A
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LABAMA
EPARTMENT OF
EVENUE
S
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T
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Reset
ST: EX-A3
ALES AND
SE
AX
IVISION
Application for State Utility/Mobile Communication
8/16
Services Tax Certificate of Exemption
Pursuant To Rule 810-6-5-.26.05
An Alabama Utility/Mobile Communication Services Tax Certificate of Exemption shall be used by persons, firms, or
corporations coming under the provisions of the Utility Gross Receipts Tax and Mobile Communication Services Tax
statutes who are not required to have a utility tax and/or mobile communication services tax license.
PLEASE COMPLETE EACH LINE APPLICABLE TO YOUR BUSINESS. A UTILITY/MOBILE COMMUNICATION
SERVICES TAX CERTIFICATE OF EXEMPTION CANNOT BE ISSUED UNTIL THIS APPLICATION IS PROPERLY
COMPLETED.
1. Federal Employer Identification Number (FEIN) _______________________ 2. Business Telephone (_____)_____________
3. ____________________________________________________ _______________________________________________________
4. Mailing address of home office _______________________________________________________________________________
Legal name of person(s), firm, corporation, association, partnership making application.
Trade name
___________________________________________________________________________________________________________
P. O. Box or Street No. or R.F.D.
5. Number of businesses in Alabama __________ Location__________________________________________________________
City
County
State
Zip Code
Location must be exact street number or, if on a highway or rural route, give details of the location. If more than one
City
Street or Hwy. No.
County
location, please attach a schedule._____________________________________________________________________________
6. Email (for renewal notification): ______________________________________________________________________________
7. Kind or class of business _____________________________________________________________________________________
8. Kind of service(s) to be purchased tax-exempt:
wholesaler, reseller, broker, etc.
Electricity
Domestic Water
Natural Gas
Telegraph
Telephone
Mobile Communication
9. REASON(S) EXEMPTION CLAIMED ________________________________________________________________________
10. Form of ownership:
Individual
Partnership
Corporation
Multi member LLC
Single member LLC
If applicant is a corporation, a copy of the certified certificate of incorporation, amended certificate of incorporation, cer-
tificate of authority, or articles of incorporation should be attached. If the applicant is a limited liability company or a lim-
ited liability partnership, a copy of the certified articles of organization should be attached.
11. Ownership information:
Corporations – give name, title, home address, and Social Security Number of each officer.
Partnerships/LLP’s – give name, home address, Social Security Number or FEIN of each partner, and valid Alabama
driver’s license or other acceptable citizenship documentation.
Sole Proprietorships – give name, home address, Social Security Number of owner, and valid Alabama driver’s license
or other acceptable citizenship documentation.
LLC – give name, home address, and Social Security Number or FEIN of each member. (Valid Alabama driver’s license
or other acceptable citizenship documentation is required for single member LLCs.)
LLP – give name, title, home address, and Social Security Number of each officer.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Signed _______________________________________________
Signed _______________________________________________
Title __________________________ Date __________________
Title __________________________ Date __________________
MAIL ORIGINAL AND ONE COPY OF THIS APPLICATION TO THE TAXPAYER SERVICE CENTER
LISTED ON THE REVERSE SIDE THAT SERVES THE COUNTY IN WHICH YOU ARE LOCATED.
Examiner’s Remarks ____________________________________________________________________________________________
REVENUE DEPARTMENT USE ONLY
_______________________________________________________________________________________________________________
Examiner _____________________________________ Date ___________________
Supervisor’s Recommendation ___________________________________________________________________________________
_______________________________________________________________________________________________________________
Supervisor _____________________________________ Date ___________________

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