Form St-Ch-1 - Application For Certificate Of Exemption For Nonprofit Child-Caring Institution, Child-Placing Agency And Maternity Home Every Question Must Be Answered In Full
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2ST-CH-1 (7/04)
STATE OF GEORGIA
DEPARTMENT OF REVENUE
1800 Century Center Boulevard, NE, Ste. 15311
Atlanta, Georgia 30345-3205
Telephone: (404) 417-6649
APPLICATION FOR CERTIFICATE OF EXEMPTION FOR
NONPROFIT CHILD-CARING INSTITUTION, CHILD-PLACING AGENCY AND MATERNITY HOME
EVERY QUESTION MUST BE ANSWERED IN FULL (Please print or type)
_______________________________________________________________________________________________________________________________________
LEGAL BUSINESS NAME
BUSINESS LOCATION/STREET ADDRESS
CITY
STATE
ZIP CODE
(PHONE NUMBER)
________________________________________________________________________________________________________________________________________________________________________________________________________________________
D/B/A NAME (IF APPLICABLE)
MAILING ADDRESS
CITY
STATE
ZIP CODE
________________________________________________________________________________________________________________________________________________________________________________________________________________________
FEDERAL EMPLOYER IDENTIFICATION NUMBER
GEORGIA WITHHOLDING TAX NUMBER
DATE FIRST OPERATED IN GEORGIA
Type of Operation:
[ ] Licensed Nonprofit Child-caring Institution [ ] Licensed Nonprofit Child-placing Agency [ ] Licensed Nonprofit Maternity Home
O.C.G.A. § 49-5-3(1)
O.C.G.A. § 49-5-3(2)
O.C.G.A. § 49-5-3(14)
.
Type of Ownership:
[ ] Individual
[ ] Corporation
[ ] Partnership
[ ] Other (Explain) _________________________________________
Primary Business Activity Percentage:
PERCENTAGE OF QUALIFING EXPENSES (LINE 14 EXPENSE WORKSHEET ON BACK PAGE)
Do you make sales? [ ] Yes. [ ] No. If yes, indicate below the type of tangible personal property sold and the frequency of sales.
________________________________________________________________________________________________________________________________________________________________________________________________________________________
TANGIBLE PERSONAL PROPERTY SOLD
FREQUENCY OF SALES
Do you lease or rent real property? [ ] Yes. [ ] No. If yes, indicate name, address and contact information of the real property lessor.
________________________________________________________________________________________________________________________________________________________________________________________________________________________
NAME
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NUMBER
Is the entity applying for this exemption licensed by the Georgia Department of Human Resources? [ ] Yes. [ ] No. If yes, attach a
copy of the entity's license issued by the Georgia Department of Human Resources.
Is the entity operating under a nonprofit charter approved by the Internal Revenue Service? [ ] Yes. [ ] No. If yes, attach a copy of the
Internal Revenue Service’s letter of determination.
In addition to the completed application and expense worksheet (on the reverse side), the following items must accompany the
application:
A detailed description of the activities or services provided by the child-caring institution, child-placing agency or maternity home.
Include any brochure, pamphlet, or similar document where the activities or services are described.
A list of the sole proprietor, partners, corporate officers or member of a limited liability company with their home or business address and
social security number or Federal Employer Identification Number.
I certify that this application, including all attachments, have been examined by me and to the best of my knowledge are true and
correct.
__________________________________________
_______________________________
(SIGNATURE AND TITLE)
(DATE SIGNED)
APPROVED BY:
__________________________________________
_______________________________
DEPARTMENT OF REVENUE
(DATE APPROVED)
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