Form St-R-35 - Application For Sale/use Tax Exemption Certificate For An Incorporated Nonprofit Rural Community Health Center Engaged In, Or Providing Facilities For The Delivery Of Comprehensive Primary Health Care
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1
2S 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 RURAL COMMUNITY HEALTH CENTER ENGAGED
IN, OR PROVIDING FACILITIES FOR THE DELIVERY OF COMPREHENSIVE PRIMARY
HEALTH CARE
Name of Corporation
_______________________________________________________
Name of Rural
Community Health Center _______________________________________________________
Physical Location
_______________________________________________________
Mailing Address
_______________________________________________________
_______________________________________________________
The statute reads, "Sales to incorporated nonprofit home health care agencies certified under the United States
Social Security Act of 1965, Title XVIII, as amended, incorporated nonprofit rural community health centers
engaged in, or providing facilities for, the delivery of comprehensive primary health care."
Is the rural community health center incorporated? Yes ___ No ___
Send a copy of the articles of incorporation!
Has the rural community health center 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 rural community health center. 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-35
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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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