Form R-1047 - Nonprofit Retirement Center Certificate Application

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R-1047 (9/12)
MAIL APPLICATIONS TO:
Louisiana Department of Revenue
Special Programs Division
Nonprofit Retirement Center
P.O. Box 66362
Baton Rouge, LA 70821-6362
Certificate Application
(225) 219-7462 Option 3 • (TDD)(225) 219-2114
La. R.S. 47:305.33
FAX: (225) 231-6236
Questions about the completion of this application should be sent
to SalesInquiries@LA.GOV
PLEASE PRINT OR TYPE.
Applicant Information
Applicant Legal Name
Louisiana Tax Number (if applicable)
Applicant Trade Name
Multipurpose Retirement Facility Name
Mailing Address
Mailing Address
City
State
ZIP
Multipurpose Retirement Facility Location Address
Location Address
City
State
ZIP
Nonprofit Retirement Center Application Questions
1. Is the retirement center owned or operated by a public trust authority?
Yes
No
 If yes, please submit documentation of ownership by public trust authority.
2. Is the retirement center a duly incorporated not-for-profit corporation?
Yes
No
 If yes, please submit documentation of IRS nonprofit status and Louisiana Secretary of State corporation charter.
3. Does your facility offer any of the following services (check all that apply)?:
Skilled Nursing Services
Hospice Care
Long Term Care
Recreational & Therapeutic Activities
Assisted Living Services
Sub-acute Care
Intermediate Healthcare
4. Please describe the services that are provided by the retirement center and provide supporting documentation that
describes these services.
Authorization
Name
Title
Signature
Date
( mm /d d / yy y y )
X

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