Form St-119.4 - Application For An Exempt Organization Certificate Power Of Attorney
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1ST-119.4 (4/01)
Taxpayer Services Division - New York State and Local Sales and Use Tax
Application for an Exempt Organization Certificate Power of Attorney
This Power of Attorney is valid only for appointing a representative to receive oral or written communications in conjunction with the review
of your organization’s application for an Exempt Organization Certificate by the Sales Tax Exempt Organizations Unit. It may not be used to
protest the denial of an application for an Exempt Organization Certificate or to request a hearing before the Division of Tax Appeals on
such a denial since your appointed representative may not be a qualified representative for these purposes. Your organization must use
Form POA-1 in these instances.
(Please print or type)
Approved Representative
Organization
Name
Name
Street address
Street address
City and state
City and state
ZIP code
ZIP code
Telephone number
State the relationship of the appointed representative to your organization
(
)
The organization named above appoints the person named above as its representative for the sole purpose of receiving all oral and written
communications and documents in connection with the organization’s application for exemption from sales and use taxes under
section 1116(a) of the Tax Law. Further, the organization named above revokes all earlier Power of Attorneys on file with the Department of
Taxation and Finance with regard to this specific matter.
Name of Officer or Trustee
Title of Officer or Trustee
/
/
Signature of Officer or Trustee
Date
This Power of Attorney must be acknowledged before a notary public or witnessed by two disinterested individuals.
Please check and complete one of the following:
Notarized
Witnessed
The officer or trustee signing this Power of Attorney
The officer or trustee signing this Power of Attorney
appeared before me this day and did acknowledge that he is
appeared before us and certified that he had the authority to
empowered to and did execute the same.
execute this Power of Attorney on behalf of the above
named organization.
Signature of Notary Public
Date
Signature of Witness
Date
Signature of Witness
Date
(SEAL)
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