Form 1746 Draft - Missouri Sales/use Tax Exemption Application 2010 Page 2
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3FORM 1746
ORGANIZATION OR AGENCY OFFICERS
6. NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NUMBER
BIRTHDATE
__
_ _ / _ _ / _ _ _ _
__ __ __ - __ __ - __ __ __
STREET ADDRESS
CITY
STATE
ZIP CODE
__ __ __ __ __
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NUMBER
BIRTHDATE
__
_ _ / _ _ / _ _ _ _
__ __ __ - __ __ - __ __ __
STREET ADDRESS
CITY
STATE
ZIP CODE
__ __ __ __ __
DESCRIPTION OF ORGANIZATION
7.
Brief statement of organizational purpose, its past, present, and proposed activities, and the intended use of the exemption letter.
ATTACHMENTS
Federal or Missouri state agencies, Missouri political subdivisions, elementary and secondary schools operated at public
expense, or schools of higher education are not required to furnish the documents requested in items 8–11 listed below.
8.
If you are a charitable, social, fraternal, civic, ministry, or religious organization, ATTACH a copy of your Internal Revenue Service
exemption letter, Federal Form 501(c). [Churches do not need to attach a 501(c).] NOTE: An IRS exemption letter does not
automatically exempt you from Missouri sales/use tax.
9.
ATTACH a copy of the Certificate of Incorporation or Registration issued by the Missouri Secretary of State, IF REGISTERED OR
INCORPORATED.
10. ATTACH a copy of your Bylaws.
11. ATTACH a complete financial history for the last three years (or number of years in existence if less than three) indicating sources
and amounts of income and a breakdown of expenditures. If just starting the organization, attach an estimated budget for one year.
12. If you are a COOPERATIVE MARKETING ASSOCIATION, attach documentation verifying your payment of the annual registration
fee and ATTACH a copy of your most recent annual report filed with the Missouri Secretary of State.
13. If you are a COOPERATIVE MARKETING ASSOCIATION, attach a copy of the articles of incorporation that details that the
corporation is organized as a nonprofit, non-stock corporation under Section 274.030 RSMo.
SIGNATURE
14. I declare under penalties of perjury that the information reported in this form and any attached supplements is true and correct as to
every material matter; that the present nature, purpose and activities of the above-named organization or agency are the same as they
were when the attached documents were issued and will continue to remain the same; that I will remain knowledgeable of the statutes
and regulations governing sales/use tax exemptions and that I will immediately notify the Missouri Department of Revenue, of any
change in circumstances which could reasonably lead me to believe that the above-named organization or agency would no longer
qualify as exempt, either because of a change in the law or because of a material change in the organization’s or agency’s nature,
purpose or activities.
It is understood that any misrepresentation contained herein or failure on my part to fulfill the promises entered into here will result in
the immediate revocation of any exemption letter issued to this organization or agency.
I also declare under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am not
eligible for any tax exemption, credit or abatement if I employ such aliens.
SIGNATURE OF OFFICER OR RESPONSIBLE PERSON
TITLE
DATE
_ _ / _ _ / _ _ _ _
MO 860-2158 (11-2010)
DOR-1746 (11-2010)
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