Form Rev-72 - Sales Tax Exemption Application Page 12
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12APPLICATION FOR
SALES TAX EXEMPTION
(6)
DOES THE INSTITUTION HAVE A WRITTEN SCHEDULE OF FEES BASED ON INDIVIDUAL OR
o
o
FAMILY INCOME?
YES
NO
(7)
ARE THE GOODS OR SERVICES PROVIDED FOR FREE OR AT A REDUCED PRICE OF
COMPARABLE QUALITY AND QUANTITY TO THE GOODS OR SERVICES PROVIDED TO THOSE
o
o
INDIVIDUALS WHO PAY A FEE GREATER THAN THE COST OF THE GOODS OR SERVICES?
YES
NO
(8)
WHAT IS THE INSTITUTION’S COST OF PROVIDING GOODS OR SERVICES TO RECIPIENTS
OF GOVERNMENT PROGRAMS, INCLUDING MEDICARE AND MEDICAID?
(9)
DOES THE INSTITUTION PROVIDE GOODS OR SERVICES FOR FREE OR AT A REDUCED RATE
o
o
TO GOVERNMENT AGENCIES?
YES
NO
(10) DOES THE INSTITUTION PROVIDE GOODS OR SERVICES TO INDIVIDUALS ELIGIBLE FOR
o
o
GOVERNMENT PROGRAMS?
YES
NO
(11) WHAT IS THE INSTITUTION’S COST OF PROVIDING GOODS OR SERVICES TO INDIVIDUALS
FOR WHOM THE INSTITUTION RECEIVES FEE-FOR-SERVICES PAYMENTS?
(12) IS THE INSTITUTION LICENSED BY THE DEPARTMENT OF HEALTH OR THE DEPARTMENT
o
o
OF PUBLIC WELFARE?
YES
NO
(13) ATTACH A LISTING OF INSTITUTIONS AND THE REASONABLE VALUE OF THE CONTRIBUTION DONATED TO EACH INSTITUTION
OF PURELY PUBLIC CHARITY OR A GOVERNMENTAL AGENCY.
(14) ATTACH A LIST BY INSTITUTION OF THE REASONABLE VALUE OF ALL CONTRIBUTIONS RECEIVED BY YOUR ORGANIZATION
FROM ANOTHER INSTITUTION OF PURELY PUBLIC CHARITY.
PART 4 – FUNDRAISING ACTIVITIES
(1)
DOES THE INSTITUTION CONTRIBUTE A SUBSTANTIAL PORTION OF FUNDS RAISED
ON BEHALF OF OR SUPPLY GRANTS TO AN ORGANIZATION RECOGNIZED AS AN
INSTITUTION OF PURELY PUBLIC CHARITY, A RELIGIOUS ORGANIZATION OR A
o
o
GOVERNMENTAL AGENCY?
YES
NO
ATTACH TO THE APPLICATION A LISTING OF THE NAMES OF ORGANIZATIONS WHO RECEIVE THE CONTRIBUTIONS AND THE AMOUNT
OF EACH CONTRIBUTION.
AUTHORIZED SIGNATURE
I, (WE) THE UNDERSIGNED, DECLARE UNDER PENALTIES OF PERJURY THAT THE STATEMENTS CONTAINED HEREIN ARE TRUE,
CORRECT AND COMPLETE.
SIGNATURE OF CORPORATE OFFICER
TITLE
TYPE OR PRINT NAME
DAYTIME TELEPHONE NUMBER
DATE
PREPARER’S NAME - TYPE OR PRINT
DATE
DAYTIME TELEPHONE NUMBER
TITLE
MAIL COMPLETED APPLICATION TO:
PA DEPARTMENT OF REVENUE
BUREAU OF BUSINESS TRUST FUND TAXES
MISCELLANEOUS TAX DIVISION
PO BOX 280909
HARRISBURG, PA 17128-0909
(717) 783-5473
1-800-447-3020 (Services for taxpayers
with special hearing and/or speaking needs)
12
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