Form R-1372 - Purchases, Leases, Or Rentals By Parochial And Private Elementary And Secondary Schools Application/exemption Certificate

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R-1372 (9/09)
(
)
Purchases, Leases, or Rentals by Parochial and
Private Elementary and Secondary Schools
Application/Exemption Certificate
Louisiana R.S. 47:301(7)(f)
Louisiana R.S. 47:301(10)(q)
Mail completed application to:
Louisiana Department of Revenue
Special Programs Division
P.O. Box 66362
Baton Rouge, LA 70896-6362
Telephone: (225) 219-7356
(TDD): (225) 219-2114 (TDD)
Approved parochial and private elementary and secondary schools may use this exemption certificate to purchase, lease or rent
educational materials or equipment used for classroom instruction. This exemption is limited to books, workbooks, computers, computer
software, films, videos, and audio tapes. Any parochial and private elementary and secondary school that fraudulently seeks to purchase,
lease or rent items other than the items listed above shall be subject to the civil and criminal penalties as provided for in the statutes.
PLEASE PRINT OR TYPE.
School Name
Daytime Telephone Number
Address
City
State
ZIP
Parish
Note: Please make sure the application is complete. Processing will be delayed or the exemption
denied if the requested documents are not provided.
Yes
No
Does the school maintain educational standards established by the State Department of Education?
(Attach a copy of the State Department of Education’s current academic certification letter.)
Yes
No Is the school in compliance with Brumfield v. Dodd?
(Attach a copy of the State Department of Education’s letter of official notification.)
Yes
No Is the school presently recognized as exempt from Federal Income Taxes?
(Attach a copy of the IRS’ determination letter for Section 501(c)(3) exempt status.)
Under the penalties of perjury, I declare that I am authorized to sign this application on behalf of the above school and that I have
examined this application, and to the best of my knowledge it is true, correct, and complete.
Name
Title
(Please Print)
(Please Print)
Signature
Date
(mm/dd/yyyy)
X
This certificate is valid as long as the approved school named above is certified by the Louisiana Department of Education. A complete
list of approved Louisiana Nonpublic Schools may be found at
FOR OFFICIAL USE
Signature of Department Representative
Date
(mm/dd/yyyy)
Approved
Disapproved

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