Fillable Form Rev-72 - Sales Tax Exemption Application (Page 5 of 12) in pdf

LINE 5 –

This figure should represent the payments the institution receives for providing education and research programs. Supply

any documentation that can support this figure.

LINE 6 –

(A) The institution must indicate whether it supplies goods or services to individuals with mental retardation or to

individuals who need mental health services.

(B) If the individual is mentally retarded or the recipient of mental health services, the institution must indicate whether

it supplies an individual’s family or guardian in support of such goods or services.

neglected or delinquent children.

If the response to any of the above three questions is YES, then answer the next question. Otherwise, skip to Part 3. Check YES or NO

as to whether any of the statutes or regulations apply to the organization.

PART 3 – GOODS OR SERVICES PROVIDED

LINE 1 –

This figure is the full cost of providing goods or services for free. The institution cannot have received partial payments

or even have attempted to collect payments. This figure is only the amounts the institution donates at 100 percent.

LINE 2 –

This figure should include the loss that is incurred by the institution charging less than the full cost of goods or services

the institution provides. This figure should not include bad debts or amounts deemed uncollectible. The cost of goods or

services should only be those goods or services associated with the institution’s charitable purpose. The cost figure should

include only actual cost incurred by the institution.

LINE 3 –

The total amount of accounts deemed uncollectible should be included here. Uncollectible amounts are those that the

institution has originally charged for, whether it be at full cost or at a discount, but for which the institution has not

received payment. This figure is not the allowance for bad debts, or the bad debt expense, nor should it include any

opportunity costs. Rather, it is only the actual cost of the goods or services provided for which the institution is unable to

collect after reasonable and customary collection efforts have failed. If the institution did receive some payment, but not

the full amount charged, include only what was uncollectible here.

LINE 4 –

Check YES if the institution has a published, written policy that it provides goods or services to anyone who seeks them

regardless of their ability to pay. If the institution does have such a written policy, attach a copy to the application.

LINE 5 –

Check YES if the institution has a published, written policy that it provides goods or services to people based upon their

ability to pay. If the institution does have such a written policy, attach a copy to the application.

LINE 6 –

Check YES if the institution has a written fee schedule that outlines how much an individual will pay based upon their

income level. A copy of the fee schedule must be enclosed with the application.

LINE 7 –

If the goods that the individuals receive at no fee or at a reduced fee are of comparable quality and quantity to the goods

or services offered at a higher cost, check YES.

LINE 8 –

The institution should calculate the cost of providing goods or services only to those individuals who are recipients of

government programs. The government programs include, among other things, Medicare and Medicaid. Supply any

documentation that can support this figure.

LINE 9 –

If the institution provides goods or services for free or at a reduced rate to government agencies or individuals eligible for

government programs, check YES.

LINE 10 – If the institution provides goods or services to individuals who are eligible for government programs, check YES.

LINE 11 – This figure represents the cost of providing goods or services to individuals for whom the institution receives fee-for-service

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

Medicare, Medicaid, Workers’ Compensation, CHAMPUS, etc. Supply any documentation that can support this figure.

The amount the institution received from the government from fee-for-service payments should be listed under Part 1,

Question 1 (Income).

Form Rev-72 - Sales Tax Exemption Application Page 5

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