Form St-Nh-1 - Application For Registration And Certificate Of Exemption Number For Nonprofit In-Patient

ST-NH-1 (REV. 06/2008)

STATE OF GEORGIA

DEPARTMENT OF REVENUE

Tax Law and Policy

1800 Century Boulevard, NE, Ste. 15311

Atlanta, Georgia 30345-3205

Telephone: (404) 417-6649

APPLICATION FOR REGISTRATION AND CERTIFICATE OF EXEMPTION NUMBER FOR NON-

PROFIT IN-PATIENT: NURSING HOMES, HOSPICES, GENERAL HOSPITALS AND MENTAL

HOSPITALS LICENSED BY THE GEORGIA DEPARTMENT OF HUMAN RESOURCES (DHR)

(Please Print)

_______________________________________________________________________________________________________________________________________

(NAME OF INSTITUTION)

(CONTACT NAME AND PHONE NUMBER)

________________________________________________________________________________________________________________________________________________________________________________________________________________________

(MAILING ADDRESS)

________________________________________________________________________________________________________________________________________________________________________________________________________________________

(LOCATION ADDRESS)

Type of Ownership:

[ ] Individual

[ ] Corporation

[ ] Partnership

[ ] Authority

[ ] Other (Explain) _________________________________________

Type of Operation:

[ ] DHR Licensed

[ ] DHR Licensed

[ ] DHR Licensed

[ ] DHR Licensed

Nonprofit

Nonprofit

Nonprofit

Nonprofit

Nursing Home

Inpatient Hospice

General Hospital

Mental Hospital

Georgia Department of Revenue Sales and Use Tax Registration Number (if applicable): __________________

Georgia Department of Revenue Withholding Tax Registration Number (if applicable): ___________________

Federal Identification Number (FEI): _________________

The following documents must be submitted with the completed application:

•

Copy of the entity’s 501(C)(3) letter issued by the Internal Revenue Service.

•

Copy of the entity’s license issued by the Georgia Department of Human Resources.

•

List of the entity’s officers responsible for the payment of sales tax and withholding tax liability including each responsible

officer’s social security number.

I certify that this application has been examined by me and to the best of my knowledge is true and correct.

_____________________ ______________ _____

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(SIGNATURE)

(DATE SIGNED)

_________________________________________

(PRINT NAME AND TITLE)

Approved:

_________________________________________

(Georgia Department of Revenue/Date)