Form 1746r - Missouri Sales/use Tax Exemption Renewal Application - 2007

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MISSOURI DEPARTMENT OF REVENUE

TAXATION BUREAU

FORM

P.O. BOX 358

1746R

JEFFERSON CITY, MISSOURI 65105-0358

MISSOURI SALES/USE TAX

(REV. 4-2007)

EXEMPTION RENEWAL APPLICATION

1. MISSOURI TAX ID NUMBER

FEDERAL ID NUMBER

(573) 751-2836

TDD 1-800-735-2966

FAX: (573) 522-1722

E-mail: salesuse@dor.mo.gov

TYPE OF EXEMPTION

2. QUALIFYING FOR EXEMPTION AS: (CHECK ONE)

functions and activities, and not for general operations of the organization)

CHARITABLE (Benefits the common good and welfare of the community,

not only within the organization, while relieving government of a financial

NOT-FOR-PROFIT CIVIC (Benefiting the citizenry at large on an unre-

burden that it would be otherwise required to meet)

stricted basis. Exemption applies only if the sale or purchase is made for

the organization’s civic or charitable functions and activities)

NOT-FOR-PROFIT SOCIAL, SERVICE, FRATERNAL (Exemption applies

only if the sale or purchase is made for the organization’s civic or charitable

ORGANIZATION NAME AND LOCATION

3. ORGANIZATION NAME

STREET ADDRESS — DO NOT USE P.O. BOX OR RURAL ROUTE

PHONE

CITY

STATE

ZIP CODE

COUNTY

IS YOUR ORGANIZATION EXEMPT FROM PROPERTY TAX?

YES

DATE ORGANIZATION ORIGINATED:

INCORPORATED ORGANIZATIONS

MISSOURI CHARTER NUMBER

DATE INCORPORATED

MISSOURI CORPORATION

MISSOURI CERTIFICATE OF AUTHORITY NO.

DATE REGISTERED IN MISSOURI

STATE OF INCORPORATION

OUT-OF-STATE CORPORATION

MAILING ADDRESS

4. MAILING ADDRESS (IF DIFFERENT THAN ORGANIZATION ADDRESS)

STREET ADDRESS OR P.O. BOX

CITY

STATE

ZIP CODE

COUNTY

WEB SITE ADDRESS

E-MAIL ADDRESS

ORGANIZATION OR AGENCY OFFICERS

5. 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

ATTACHMENTS

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.

Provide a written description of civic or charitable activities. Please be specific and provide examples.

SIGNATURE

12. I swear or affirm 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.

SIGNATURE OF OFFICER OR RESPONSIBLE PERSON

TITLE

DATE

MO 860-xxxx (4-2007)

DOR-1746R (4-2007)