Form Ft-937 - Certificate Of Exemption For Qualified Hospitals, Volunteer Fire Companies And Volunteer Ambulance Services

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FT-937
New York State Department of Taxation and Finance
Certificate of Exemption for Qualified
(9/11)
Hospitals, Volunteer Fire Companies and
Volunteer Ambulance Services
This form will be acceptable as proof of exemption from the sales and use tax or motor fuel tax only if all entries are completed and the
supporting photocopies are attached.
To be completed by the purchaser and given to the seller. See instructions on the back before completing this form.
Name of seller
Name of purchaser
Street address
Street address
City
State
ZIP code
City
State
ZIP code
Part 1 — Hospitals’ purchases of motor fuel (exempt from all New York State and local sales and use tax and
motor fuel tax; subject to the petroleum business tax)
I certify that the motor fuel is being purchased by and for the use of the above named hospital and that this hospital:
holds a valid operating certificate number
issued by the New York State Department of Health or
New York State Department of Mental Hygiene (copy attached) and
holds a valid Form ST-119, Exempt Organization Certificate, number EX
(copy also attached).
Part 2 —Volunteer fire companies’ and ambulance services’ purchases of motor fuel or diesel motor fuel
(exempt from all New York State and local sales and use tax; subject to the motor fuel or diesel motor
fuel tax and the petroleum business tax at the motor fuel rate or the highway diesel motor fuel
rate)
I certify that the motor fuel or diesel motor fuel is being purchased by and for the use of the above named volunteer fire company or
ambulance service and that:
the volunteer fire company or ambulance service has a valid Form ST-119, Exempt Organization Certificate, number
EX
(copy attached), and
the fuel is for use in firefighting vehicles, apparatus or equipment, or emergency rescue or first aid response vehicles, apparatus
or equipment, owned and operated by the fire company or ambulance service.
Type or print name and title of officer of organization
Signature of officer of organization
Date
Evasion of New York State taxes due on motor fuel or diesel motor fuel in New York State is a felony. In addition, any person
who attempts to use this form to evade the taxes on motor fuel or diesel motor fuel will be subject to penalties as provided by
the New York State Sales Tax, Motor Fuel/Diesel Motor Fuel Tax and Petroleum Business Tax Laws and Regulations.

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