Form Rev-72 - Sales Tax Exemption Application Page 10
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12APPLICATION FOR
SALES TAX EXEMPTION
(2)
EXPENSES – LIST THE EXPENSES DIRECTLY RELATED TO THE INSTITUTION’S CHARITABLE PURPOSE AND THEIR RESPECTIVE
AMOUNTS. ATTACH ADDITIONAL SHEETS TO THE APPLICATION. (NOTE: ANY EXPENSES NOT INCLUDED IN THIS SECTION MAY
BE SUBJECT TO SALES OR USE TAX.) IRS FORM 990 MAY BE SUBSTITUTED.
ACTIVITY
DOLLAR AMOUNT
TOTAL EXPENSES
(INCLUDING AMOUNTS LISTED
ON SEPARATE SHEETS)
(3)
DOES THE INSTITUTION HAVE A VOLUNTARY AGREEMENT (i.e. PILOT, SILOT, etc.) WITH A
o
o
POLITICAL SUBDIVISION? ATTACH A COPY OF EACH AGREEMENT WITH THE APPLICATION.
YES
NO
(4)
VOLUNTEERS – THE INSTITUTION MAY ELECT TO LIST THE NAME OF EACH VOLUNTEER, ALONG WITH THE NUMBER OF HOURS
WORKED EACH WEEK AND THE NUMBER OF WEEKS VOLUNTEERED FOR THE YEAR. ALTERNATIVELY, THE INSTITUTION MAY
BREAK OUT THE LIST ACCORDING TO THE NUMBER OF VOLUNTEERS WHO CONTRIBUTE THE SAME NUMBER OF HOURS EACH
WEEK AND WEEKS EACH YEAR. A LISTING BY NAMES AND HOURS WORKED SHOULD BE AVAILABLE FOR INSPECTION BY THE
DEPARTMENT IF REQUESTED. ATTACH ADDITIONAL SHEETS AS NEEDED.
YEAR FROM WHICH VOLUNTEER DATA WAS GATHERED:
NAME OF INDIVIDUAL OR NUMBER OF INDIVIDUALS
HOURS PER WEEK
WEEKS PER YEAR
(5)
A. HOW MANY PEOPLE RECEIVE GOODS OR SERVICES FROM THE INSTITUTION?
B. HOW MANY REGISTERED MEMBERS ARE IN YOUR ORGANIZATION/CHURCH?
(6)
HOW MANY PEOPLE RECEIVE THE GOODS OR SERVICES FOR FREE?
(7)
HOW MANY PEOPLE PAY A REDUCED FEE FOR THE GOODS OR SERVICES?
(8)
DO ANY OF THE PEOPLE RECEIVING GOODS OR SERVICES PAY A FEE EQUAL TO OR
o
o
GREATER THAN THE COST OF THE GOODS OR SERVICES PROVIDED TO THEM?
YES
NO
(9)
WHAT NUMBER OF INDIVIDUALS RECEIVE FINANCIAL ASSISTANCE FROM THE INSTITUTION?
(10) AFTER SUBTRACTING THE FINANCIAL ASSISTANCE GRANTED BY THE INSTITUTION, HOW
MANY INDIVIDUALS PAID A FEE 90 PERCENT OR LESS OF THE COST OF THE GOODS OR
SERVICES PROVIDED TO THEM?
Volunteer fire companies and churches should stop here and turn to Page 12 to complete the authorized signature.
PART 2 – RECIPIENT INFORMATION
(1)
WHAT PERCENTAGE OF INDIVIDUALS RECEIVING GOODS OR SERVICES FROM THE
INSTITUTION RECEIVE A REDUCTION IN FEES OF AT LEAST 10 PERCENT OF THE COST
OF THE GOODS OR SERVICES PROVIDED TO THEM?
(2)
WHAT IS THE COST OF PROVIDING COMMUNITY SERVICES PROVIDED BY OR PARTICIPATED
IN BY THE INSTITUTION? ATTACH A COPY OF SUPPORTING DOCUMENTATION TO
THE APPLICATION.
(3)
WHAT AMOUNT DOES THE INSTITUTION RECEIVE AS PAYMENTS TO SUPPORT SUCH
COMMUNITY SERVICES? ATTACH A COPY OF SUPPORTING DOCUMENTATION TO
THE APPLICATION.
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