Form As 2645.1 - Application For Tax Exemption Under Section 1101.01 Of The Internal Revenue Code For A New Puerto Rico Page 4
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5Form AS 2645.1
Page 4 of 4
Rev. Oct 26 11
Name ___________________________________________
YES NO
Does the organization provide services or products? ....................................................................................
21.
If the answer is yes:
a.
Do the recipients of these services or products have to pay for them? .......................................................
b.
Explain how the payment is determined, if any _________________________________________________
c.
Are the services or products offered by your organization available only to certain individuals or type of
individuals? ................................................................................................................................................
22.
Does the organization participate in political campaigns, including the publication or distribution of proposals?
If the answer is yes, explain thoroughly.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
23.
Do you have employees that receive salaries or wages? ...................................................................................
If the answer is yes, indicate if you complied with the following:
a.
Did you make the withholding of tax at source on wages paid? ....................................................................
b.
Did you file the Withholding Statements, the Employer's Quarterly Returns of Income Tax Withheld and the
Reconciliation Statement of Income Tax Withheld? ........................................................................................
24.
Do you have persons under service contracts? ............................................................................................
If your answer is yes, indicate if you complied with the following:
a.
Have you made the 7% withholding at source on payments for services rendered, as provided by Section
1062.03 of the Code? ...........................................................................................................................
b.
Did you file the Informative Returns? ......................................................................................................
c.
Have you made any withholding at source to any nonresident not engaged in trade or business in Puerto
Rico? ........................................................................................................................................................
25.
Is the organization under an investigation by the Department of the Treasury or other Governmental Agency of
Puerto Rico? ............................................................................................................................................
If the answer is yes, indicate the Agency and the aspects that are subject of controversy in the investigation.
___________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
I, ________________________________, hereby declare today ___________________ under penalty of perjury, that I
am authorized to sign this application on behalf of___________________________, that such application and documents
included have been examined by me, and to the best of my knowledge and belief they are true, correct and complete.
____________________________________
____________________________________
Signature
Title
______________________
Date
This form and the required documents should be filed at the Assistant Secretary for Internal Revenue Office (Office 620),
Intendente Alejandro Ramírez Building, 10 Paseo Covadonga, San Juan or by mail to the DEPARTMENT OF THE TREASURY,
ASSISTANT SECRETARY FOR INTERNAL REVENUE, PO BOX 9024140 SAN JUAN PR 00902-4140.
Retention: Fifty (50) years.
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