Form St:ex-A3 - Application For State Utility/cellular Services Tax Certificate Of Exemption
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ST: EX-A3
LABAMA
EPARTMENT OF
EVENUE
5/99
S
, U
& B
T
D
ALES
SE
USINESS
AX
IVISION
Montgomery, Alabama 36132
Application for State Utility/Cellular Services Tax
Certificate of Exemption
Pursuant To Rule 810-6-5-.26.05
An Alabama Utility/Cellular Services Tax Certificate of Exemption shall be used by persons, firms, or corporations
coming under the provisions of the Utility Gross Receipts Tax and Cellular Telecommunication Services Tax statutes who
are not required to have a utility tax and/or cellular services tax license.
PLEASE COMPLETE EACH LINE APPLICABLE TO YOUR BUSINESS. A UTILITY/CELLULAR SERVICES TAX
CERTIFICATE OF EXEMPTION CANNOT BE ISSUED UNTIL THIS APPLICATION IS PROPERLY COMPLETED.
1. Federal Employer Identification Number (FEIN) _______________________ 2. Business Telephone (_____)_____________
3. ___________________________________________________________________________________________________________
Legal name of person(s), firm, corporation, association, partnership making application.
___________________________________________________________________________________________________________
Trade name
4. Mailing address of home office _______________________________________________________________________________
P. O. Box or Street No. or R.F.D.
___________________________________________________________________________________________________________
City
County
State
Zip Code
5. Number of businesses in Alabama __________ Location__________________________________________________________
City
Street or Hwy. No.
County
Location must be exact street number or, if on a highway or rural route, give details of the location. If more than one
location, please attach a schedule._____________________________________________________________________________
6. Kind or class of business _____________________________________________________________________________________
wholesaler, manufacturer, etc. and type of product or service manufactured, sold or provided
7. Kind of service(s) to be purchased tax-exempt:
Electricity
Domestic Water
Natural Gas
Telegraph
Telephone
Cellular
8. REASON(S) EXEMPTION CLAIMED ________________________________________________________________________
___________________________________________________________________________________________________________
9. Form of ownership:
Individual
Partnership
Corporation
Multi member LLC
Single member LLC
LLP
Other ________________________________________
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.
10. Ownership information:
Corporations – give name, title, home address, and Social Security Number of each officer.
Partnerships/LLP’s – give name, home address, and Social Security Number or FEIN of each partner.
Sole Proprietorships – give name, home address, and Social Security Number of owner.
LLC – give name, home address, and Social Security Number or FEIN of each member.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
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.
REVENUE DEPARTMENT USE ONLY
Examiner’s Remarks ____________________________________________________________________________________________
_______________________________________________________________________________________________________________
Examiner _____________________________________ Date ___________________
Supervisor’s Recommendation ___________________________________________________________________________________
_______________________________________________________________________________________________________________
Supervisor _____________________________________ Date ___________________
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