New York State Department of Taxation and Finance
Annual Report of Sales and Use Tax Exemptions
Claimed by Agent/Project Operator of
Industrial Development Agency/Authority (IDA)
For Period Ending December 31,
Name of IDA agent/project operator
Federal employer identification number (FEIN)
Name of IDA agent/project operator’s authorized representative, if any
Name of IDA
Name of project
Street address of project site
1 Project purpose
Agriculture, forestry, fishing
(mark an X
in the appropriate box)
Finance, insurance or real estate
Transportation, communication, electric, gas, or sanitary services
2 Date project began (mm/dd/yy):
3 Beginning date of construction or installation (mm/dd/yy; see instructions):
4 Completion date of construction phase of project (mm/dd/yy; see instructions):
5 Completion date of project (mm/dd/yy; see instructions):
6 Duration of project (actual or expected; years/months):
7 Total sales and use tax exemptions (actual tax savings; NOT total purchases) .............................
Certification: I certify that the above statements are true, complete, and correct, and that no material information has been omitted. I
make these statements with the knowledge that willfully providing false or fraudulent information with this document may constitute a
felony or other crime under New York State Law, punishable by a substantial fine and possible jail sentence. I also understand that the Tax
Department is authorized to investigate the validity of any information entered on this document.
Print name of officer, employee, or authorized representative signing for the IDA agent/project operator Title of person signing
Failure to annually file a complete report may result in the removal of authority to act as an IDA agent/project operator.
Mail completed report to: NYS Tax Department, IDA Unit, W A Harriman Campus, Albany NY 12227.