Application Form For Sales And Use Tax Exemption For Nonprofit Organizations Form (2012)
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4Virginia Department of Taxation
Application for Sales and Use Tax Exemption for Nonprofit Organizations
Please read instructions carefully before completing this form.
For assistance call (804) 371-4023
:
Completed form can be mailed or faxed to
Virginia Department of Taxation
Nonprofit Exemption Unit
Post Office Box 27125
Richmond, VA 23261-7125
FAX Number - (804) 786-2645
Section I- Part 1: Reason For Submitting Form
Please check the appropriate box that applies to your request. See page 1of the instructions.
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New Exemption Application
Renewal Application
Part 2
Internal Revenue Service - Exempt Designation
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If your organization is exempt from federal income tax under sections 501(c)(3) or (c)(4), please check the
appropriate box. See page 1 of the instructions.
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501(c)(3)
501(c)(4)
Section II - Business Information
1.
Enter Legal Name of the Organization: ___________________________________
Enter organization’s Federal Employer Identification Number (FEIN): _______________________
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Enter physical address of the organization. See page 1 of the instructions.
Street ____________________________________________________________________
City _________________________________ State _______________
Zip Code ____________
4.
Enter address if different from the physical address, where the financial records of the organization are
available for public inspection (certificate mailed to the physical address). See page 1 of the instructions.
_______________________________________________________________________________
_______________________________________________________________________________
5.
Enter name and mailing address of a contact person for the organization. See page 1 of the instructions.
Name ___________________________________
Telephone Number ___________________
Title __________________________________________________________________________
Street _________________________________________________________________________
City ________________ State ________________ Zip Code _________________
__________________
FAX Number ___________________
E-mail address
6.
Check the box that best describes the primary purpose of the organization (choose only one). See page 2 of the
instructions.
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Civic and Community Service
Educational
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Church
Medical
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Cultural
Other
Va. Dept. of Taxation
Rev. (1/1/2012)
Page
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