Request For Extension Of Sales And Use Tax Exemption - Virginia Department Of Taxation Page 5

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SECTION D: SIGNATURES
This form must be completed with all required documentation attached, and timely filed in
accordance with Code of Virginia § 30-19.05.
WAIVER: The information provided in this request for Sales and Use Tax exemption shall NOT
be subject to the secrecy of information provisions of Code of Virginia §§ 30-28.18 or 58.1-3, or
any other secrecy of information provisions thereof, and shall become a part of the public
legislative record. However, this information may not be used for any purpose other than as part
of the legislative record.
Signature of Delegate/Senator Sponsoring Exemption
___________________________________________________________ Date _________________
Print Name of Delegate/Senator Sponsoring Exemption
__________________________________________________________________________________
The undersigned certifies that this organization’s financial records are true, accurate, and
complete.
___________________________________________________________ Date _________________
Business Authorized Representative*
*Required only if exemption applies to one business/organization
MAILING INFORMATION
Send completed form with attachments or change of address to:
Virginia Department of Taxation
Virginia Department of Taxation
Policy Development
or
Policy Development
P. O. Box 1880
2220 West Broad Street
Richmond, Virginia 23218-1880
Richmond, Virginia 23220

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