Form St-R-42 - Application For Sale/use Tax Exemption Certificate For An Incorporated Nonprofit Statewide Organization That Advocate For Children And That Are Members Of The Medicaid Advisory Committee

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S 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 STATEWIDE ORGANIZATION THAT ADVOCATE FOR
CHILDREN AND THAT ARE MEMBERS OF THE MEDICAID ADVISORY COMMITTEE
Name of Corporation
_______________________________________________________
Name of Organization
_______________________________________________________
Physical Location
_______________________________________________________
Mailing Address
_______________________________________________________
_______________________________________________________
_______________________________________________________
The statute reads, "Statewide organizations that advocate for children and that are members of the Medicaid
Advisory Committee."
Is the organization incorporated? Yes ___ No __
Send a copy of the articles of incorporation
Has the organization 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 IRS determination letter indicating 501(c) nonprofit status
I hereby certify that ______________________________________________________ is an incorporated
nonprofit organization. I therefore request that a sales/use tax exemption certificate be issued to the above
organization pursuant to Title 36 MRSA 1760 (49).
Date:
Signature: ___________________________________________
Tel:
Print Name: __________________________________________
Fed ID# _______________________
Title: ________________________________________________
Date Facility Opened: __________________________________
ST-R-42
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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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