Form 21919 - Application For Sales Tax Exemption Certificate printable pdf download

Form 21919 - Application For Sales Tax Exemption Certificate

North Dakota

Office Use Only

Application For Sales Tax Exemption

Certificate

Office of State Tax Commissioner

Sales Tax Compliance

State Capitol

Bismarck, ND 58505-0599

This application should be filed only by federal, state, or local governments; federal corporations; schools; hospitals, nursing homes,

intermediate care facilities and basic care facilities licensed by the State Department of Health; and voluntary health associations recog-

nized by the National Health Council.

Name of Organization

Name

Federal Identification Number (FEIN)

Phone Number

Street Address

City

State

Zip Code

Location

PO Box or Street Address

City

State

Zip Code

Mailing Address

(If Different From

Above)

❏ Federal

❏ Public or Private School, College or University

❏ State

❏ Hospital or Nursing Home (License No. ________________)

Type of

❏ County or Township

❏ Intermediate or Basic Care Facility License No. (__________)

❏ City

❏ Voluntary Health Association

Organization

Provide explanation of primary function of organization _______________________________

(Check One)

_______________________________________________________________________________

❏ Yes

❏ No

(1) Does the organization hold a sales and use tax permit?

❏ Yes

❏ No

(2) Does the organization make any retail sales?

Authorized Purchasing Agent ________________________________________________________________________________

Name

Title

Phone Number

I certify that the above statements are correct to the best of my knowledge and belief and that I am authorized to sign this

application

Signed _________________________________________

Title ________________________________________

Print Name ______________________________________

Date ________________________________________

IMPORTANT: The Certificate of Exemption, if granted, applies to purchases only. It does not apply to the sale of tangible personal property. As soon as your

application is approved, a Certificate will be mailed. This certificate must be retained by you and a copy of your certificate must be furnished to all suppliers or

retailers at the time of purchase.

21919

(Rev. 7/97)

Form 21919 - Application For Sales Tax Exemption Certificate

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