Application For Sales Tax Exemption (REV-72)

1 1 SECTION 1 REGISTRATIONI nstitutions seeking Exemption from Sales and use tax must complete this Application . Section 1 must be completed by all follow the instructions carefully to ensure all pertinent information and supporting documentation are supplied. All sections ofthe Application must be completed in black ONE OF THE FOLLOWING:NEW REGISTRATION:Applies to an institution that has never been registered with the PA Department of Exemption STATUS:Applies to an institution that was previously registered with the PA Department of Revenue, buthas since ceased operations, failed to renew or whose Exemption status was UPDATE:Applies to an institution that is currently exempt, but is seeking to have its Exemption statusrenewed for another DOCUMENTS - The documents identified below must be submitted along with this Application .

2 Please checkall boxes pertaining to your organization. Please include copies of the documents with the completed DOCUMENTATION CHECKLISTAN INCORPORATED INSTITUTION MUST PROVIDE A COPY OF THE ARTICLES OF INCORPORATION SPECIFICALLY INCLUDING APROVISION PROHIBITING THE USE OF ANY SURPLUS FUNDS FOR PRIVATE INUREMENT TO ANY PERSON IN THE EVENT OF A SALEOR DISSOLUTION OF THE UNINCORPORATED INSTITUTION MUST PROVIDE A COPY OF THE BYLAWS OR ANY GOVERNING DOCUMENT SPECIFICALLYINCLUDING A PROVISION PROHIBITING THE USE OF ANY SURPLUS FUNDS FOR PRIVATE INUREMENT TO ANY PERSON IN THEEVENT OF A SALE OR DISSOLUTION OF THE ORGANIZATION MUST PROVIDE A COPY OF THE MOST CURRENT FINANCIAL STATEMENT (A NEW ORGANIZATION CANSUBSTITUTE A PROPOSED BUDGET), INCLUDING ALL INCOME AND EXPENSES LISTED BY SOURCE AND THE INSTITUTION HAS BEEN GRANTED Exemption BY THE INTERNAL REVENUE SERVICE (IRS), PROVIDE A COPY OF THEDETERMINATION THE INSTITUTION FILES IRS FORM 990, RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX, PROVIDE A COPY OF THEMOST RECENTLY COMPLETED FORM WITH THE A INSTITUTION INFORMATIONINSTITUTION LEGAL NAME:Enter the legal name of the EIN:Enter the Federal Employer Identification Number (EIN) assigned to the institution by the IRS.

3 Ifthe institution does not have an EIN, enter N/A. If the institution submitted an Application for anEIN, enter applied for. INSTITUTION TRADE NAME:Enter the name the institution is commonly known by (doing business as), if it is a name other thanthe legal name. If the trade name is the same as the legal name, enter same. TELEPHONE NUMBER:Enter the telephone number for the ADDRESS:Enter the physical location of the institution. A post office box is not OF FIRST OPERATIONS:Enter the first date the institution conducted any OF INSTITUTION S Enter the address where the institution s records are kept. A post office box is not :Be sure to include the name of the ADDRESS:Enter the address where the institution prefers to receive mail, if at an address other than theinstitution s street address.

4 A post office box is FORSALES TAX Exemption APPLICATIONREV-72 (TR) 04-17 Fax or email completedapplication to:Fax: 717-787-3708 Email: B TYPE OF ORGANIZATIONC heck the box or fill in the blank to indicate the type of organization that applies to the institution. Examples would include soleproprietorship, partnership, corporation and association. Enter the date of incorporation and the state of incorporation. If the institution is not incorporated, enter N/A. Check the box to indicate whether the institution is operated for profit or as a nonprofit the institution has applied to and been approved by the IRS as tax-exempt, indicate under which section of the Internal RevenueCode the institution qualifies. Institutions are under a continuing obligation to immediately notify the PA Department of Revenue if thereis any change in this status.

5 If an institution has not applied with the IRS, enter N/A. All institutions are under a mandatory continuing obligation to report to the Pennsylvania Department of Revenue any change inexemption status with the IRS. Institutions are required to report all changes within 10 days in writing to the department. Such changesinclude but are not limited to a revocation of the Exemption status or receiving an individual Exemption where the organization waspreviously covered under a group Exemption institutions are under a mandatory continuing obligation to report to the Pennsylvania Department of Revenue any court decisionthat may affect the institution s tax Exemption status. The court decision may be within the state of Pennsylvania or any otherjurisdiction.

6 Institutions are required to report all changes within 10 days in writing to the institutions are under a mandatory continuing obligation to report to the Pennsylvania Department of Revenue if the organization iscurrently being challenged by the IRS, the Commonwealth of Pennsylvania, a political subdivision or any for-profit entity. Institutions arerequired to report this information within 10 days in writing to the correspondence should be sent to: Fax: 717-787-3708 Email: C ORGANIZATION INFORMATIONAll activities carried on by the institution for a period of three years should be reported. This explanation must contain a detaileddescription of how the beneficiaries are selected.

7 Additional sheets can be attached to the Application , should the response require moreroom than the space provided. If bylaws or IRS Form 990 explain the organizational purpose in detail, those documents can be usedto complete this section. Attach any additional documentation such as brochures or pamphlets that explain the institution s D AFFILIATE INFORMATIONIn this section indicate whether the institution is affiliated with another organization. Affiliate is defined as a domestic or foreigncorporation, association, trust or other organization that owns a 10 percent or greater interest in an institution of purely public definition also includes situations where an institution of purely public charity owns a 10 percent or greater interest in a domesticor foreign corporation, association, trust or other attach an organizational chart to the a parent institution to be considered an other nonprofit entity for purposes of Act 55, all of its subsidiaries must first qualify asan institution of purely public charity.

8 An organization seeking to qualify as an other nonprofit entity is only required to completeSection E OFFICER INFORMATIONE nter the requested information for each officer. Additional sheets should be attached if the institution has more than four officers. Thissection must be completed even if the officers are not paid a salary from the organization. Organizations that complete IRS Form 990may 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 taxesand 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, expenseaccounts and automobile F SALARY INFORMATIONAll organizations must complete this section.

9 Organizations that file IRS Form 990 and complete Schedule A may substitute Schedule Aof the most recently completed :List the names of the highest paid individuals within the organization, excluding the officers whowere listed in Subsection E. POSITION:Indicate what positions they hold within the institution, , director, manager. SALARY:Indicate their current salaries from the organization before taxes and other exclusions. OTHER BENEFITS ANDList the benefits each individual receives in addition to salary, and include the value of each OF EACH:Such benefits include but are not limited to health insurance programs, life insurance, expenseaccounts and automobile 2 FINANCIAL INFORMATIONAll institutions must complete Part 1, Basic Questions, and all remaining parts as applicable.

10 Volunteer fire companies and churches areonly required to complete Part 1, Basic Questions. Organizations engaging only in fundraising activities should complete Part 1, BasicQuestions and Part 4, Fundraising Activities. It is recommended that colleges and universities answer Part 1, Basic Questions as well asPart 2, Recipient Information, Questions 1, 4 and 5 to qualify. All other types of institutions should complete all of the parts as 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 completedfiscal years. If the institution does average the financial information, all financial statements used in the calculations must be submittedwith the Application .