Form St-R-31 - Application For Sale/use Tax Exemption Certificate For An Incorporated Nonprofit Nursing Home
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1S T A T E O F M A I N E
M A I N E R E V E N U E S E R V I C E S
ADMINISTRATIVE & FINANCIAL
2 4
S T A T E H O U S E S T A T I O N
SERVICE
,
A U G U S T A
M A I N E
REBECCA M. WYKE
0 4 3 3 3 - 0 0 24
COMMISSIONER
John Elias Baldacci
JEROME D. GERARD
GOVERNOR
ACTONG EXECTUTIVE DIRECTOR
APPLICATION FOR SALE/USE TAX EXEMPTION CERTIFICATE
FOR AN INCORPORATED NONPROFIT NURSING HOME
Name of Corporation
_______________________________________________________
Name of Nursing Home
_______________________________________________________
Physical Location
_______________________________________________________
Mailing Address
_______________________________________________________
_______________________________________________________
_______________________________________________________
The statute reads, incorporated nonprofit nursing homes licensed by the Department of Behavioral and
Developmental Services,"
Is the nursing home incorporated? Yes ___ No __
Send a copy of the articles of incorporation
Is the nursing home licensed by the Department of Behavioral and Developmental Services? Yes___ No ___
Send a copy of the nursing home license received by the Department of Behavioral and Developmental Services
Has the nursing home received 501(c) nonprofit status from the IRS? Yes ___No ___
Send a copy of the IRS determination letter indicating 501(c) nonprofit status
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 nursing home license from the Department of Behavioral and Developmental Services
3. Copy of the IRS determination letter indicating 501(c) nonprofit status
I hereby certify that ______________________________________________________ is an incorporated
nonprofit nursing home licensed by the Department of Behavioral and Developmental Services. 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-31
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E A R I N G
M P A I R E D
H O N E
E-mail:
sales.tax@state.me.us
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