Fillable Form Rev-72 - Sales Tax Exemption Application (Page 3 of 12) in pdf

SUBSECTION E – OFFICER INFORMATION

Enter the requested information for each officer. Additional sheets should be attached if the institution has more than four officers. This

section must be completed even if the officers are not paid a salary from the organization. Organizations that complete IRS Form 990

may substitute Part V of the most recently completed return.

ANNUAL COMPENSATION:

Indicate what each officer receives in the form of compensation from the organization before taxes

and other payroll deductions.

OTHER BENEFITS AND

List the benefits each officer receives in addition to salary, and include the value of each benefit.

AMOUNTS OF EACH:

Such benefits include but are not limited to health insurance programs, life insurance, expense

accounts and automobile usage.

SUBSECTION F – SALARY INFORMATION

All organizations must complete this section. Organizations that file IRS Form 990 and complete Schedule A may substitute Schedule A

of the most recently completed return.

NAME:

List the names of the highest paid individuals within the organization, excluding the officers who

were listed in Subsection E.

POSITION:

Indicate what positions they hold within the institution, i.e., director, manager.

SALARY:

Indicate their current salaries from the organization before taxes and other exclusions.

OTHER BENEFITS AND

List the benefits each individual receives in addition to salary, and include the value of each benefit.

AMOUNTS OF EACH:

Such benefits include but are not limited to health insurance programs, life insurance, expense

accounts and automobile usage.

SECTION 2 – FINANCIAL INFORMATION

All institutions must complete Part 1, Basic Questions, and all remaining parts as applicable. Volunteer fire companies and churches are

only required to complete Part 1, Basic Questions. Organizations engaging only in fundraising activities should complete Part 1, Basic

Questions and Part 4, Fundraising Activities. It is recommended that colleges and universities answer Part 1, Basic Questions as well as

Part 2, Recipient Information, Questions 1, 4 and 5 to qualify. All other types of institutions should complete all of the parts as applicable.

An institution may answer “NO” or “N/A” to any question that does not pertain to the institution.

An institution may either use the current year’s financial data or average the financial information for the five most recently completed

fiscal years. If the institution does average the financial information, all financial statements used in the calculations must be submitted

with the application. Institutions electing to average financial data should indicate the years from which they have used the data in the

space provided.

PART 1 – BASIC QUESTIONS

LINE 1 –

INCOME – List each activity from which the institution receives revenue. This question must be completed by all institutions.

A contribution includes any promise, grant, pledge or gift of money, property, goods, services, financial assistance or other

similar remittance. It includes amounts received from individuals, trusts, corporations, estates and foundations, or raised

by an outside professional fund-raiser.

A fee-for-service payment is any payment received under any governmental program. This would include Medicare,

Medicaid, Workers’ Compensation, CHAMPUS, etc. Break out amounts according to the various programs.

LINE 2 –

EXPENSES – List each expense the institution incurs as a result of its charitable activity. Examples include salaries, supplies,

equipment costs, postage and handling. All organizations must complete this question. If the institution completes

IRS Form 990, the institution should attach a copy of the most recently completed year and may skip this question.

The year of the IRS Form 990 must be identical to the year from which the remaining financial data is taken.

Form Rev-72 - Sales Tax Exemption Application Page 3

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