Form Rev 72 As – Fill Out and Use This PDF

REV-72AS(11-06)

MAILCOMPLETEDAPPLICATION TO:

PADEPARTMENTOF REVENUE

PENNSYLVANIA

BUREAU OF BUSINESS TRUSTFUND TAXES

DEPARTMENT OF

PO BOX 280909

EVENUE

HARRISBURG, PA17128-0909

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENTOF REVENUE

INSTRUCTIONS FOR

SALES TAX EXEMPTION APPLICATION

SECTION 1 – REGISTRATION

Institutions seeking exemption from Sales and Use Tax must complete this application. Section 1 – Registration must be completed by all institutions. Please follow the instructions carefully to insure all pertinent information and supporting documentation are supplied. All sections of the application must be completed in black ink.

SELECT ONE OF THE FOLLOWING:

NEW REGISTRATION: Applies to an institution that has never been registered with the PADepartment of Revenue.

EXPIRED EXEMPTION STATUS: Applies to an institution that was previously registered with the PADepartment of Revenue, but has sinceceased operations, failed to renew, or whose exemption status was canceled.

RENEWALUPDATE:	Appliestoaninstitutionthatiscurrentlyexempt,butisseekingtohaveitsexemptionstatusrenewed
	for another term.

REQUIRED DOCUMENTS - The below documents are required to be submitted along with this application. Please check all boxes pertaining to your organization. Mail copies of the documents with the completed application.

REQUIRED DOCUMENTATION CHECKLIST

INCORPORATEDINSTITUTIONSMUSTPROVIDEACOPYOFTHEARTICLESOFINCORPORATIONSPECIFICALLYINCLUDINGAPROVISIONPROHIBITINGTHEUSE OFANYSURPLUS FUNDS FOR PRIVATE INUREMENT TOANYPERSON IN THE EVENT OFASALE OR DISSOLUTION OF THE INSTITUTION.

UNINCORPORATED INSTITUTIONS MUST PROVIDEACOPYOF THE BYLAWS ORANYGOVERNING DOCUMENT SPECIFICALLYINCLUDINGAPROVISION PRO- HIBITING THE USE OFANYSURPLUS FUNDS FOR PRIVATE INUREMENT TOANYPERSON IN THE EVENT OFASALE OR DISSOLUTION OF THE INSTITUTION.

ALL ORGANIZATIONS MUST PROVIDE A COPY OF THE MOST CURRENT FINANCIAL STATEMENT (NEW ORGANIZATIONS CAN SUBSTITUTE A PROPOSED BUDGET) INCLUDINGALLINCOMEAND EXPENSES LISTED BYSOURCEAND CATEGORY.

IF THE INSTITUTION HAS BEEN GRANTED EXEMPTION BYTHE INTERNALREVENUE SERVICE (IRS), PROVIDEACOPYOF THE DETERMINATION LETTER.

IF THE INSTITUTION FILES FORM 990, PROVIDEACOPYOF THE MOST RECENTLYCOMPLETED FORM WITH THEAPPLICATION.

SUBSECTION A – INSTITUTION INFORMATION

INSTITUTION LEGALNAME: Enter the legal name of the institution.

FEDERALEIN: Enter the Federal Employer Identification Number (EIN) assigned to the institution by the Internal Revenue Service. If the institution does not have an EIN, enter “n/a.” If the institution has made application for an EIN, enter “applied for.”

INSTITUTION TRADE NAME: Enter the name the institution is commonly known by (doing business as), if it is a name other than the legal name. If the trade name is the same as the legal name, enter “same.”

TELEPHONE NUMBER: Enter the telephone number for the institution.

STREET ADDRESS: Enter the physical location of the institution. Apost office box is not acceptable.

DATE OF FIRST OPERATIONS: Enter the first date the institution conducted any activity.

LOCATION OF INSTITUTION’S Enter the address where the institution’s records are kept. A post office box is not acceptable.

RECORDS: Be sureto include the name of the county.

MAILING ADDRESS: Enter the address where the institution prefers to receive mail, if at an address other than the institution’s street address. Apost office box is acceptable.

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SUBSECTION B – FORM OF ORGANIZATION

Check the box or fill in the blank to indicate the form of organization that applies to the institution. Examples would include sole proprietorship, 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 organization.

If the institution has applied to and been approved by the Internal Revenue Service as tax-exempt, indicate under which section of the Internal Revenue Code the institution qualifies. Institutions are under a continuing obligation to immediately notify the PADepartment of Revenue if there is any change in this status. If an institution has not applied to the Internal Revenue Service, enter “n/a.”

All institutions are under a mandatory continuing obligation to report to the PADepartment of Revenue any change in their exemption status with the Internal Revenue Service. Institutions are required to report all changes within ten days in writing to the Department. Such changes would include, but are not limited to, a revocation of the exemption status or receiving an individual exemption where the organization was previously covered under a group exemption status.

All institutions are under a mandatory continuing obligation to report to the PADepartment of Revenue any court decision that may affect the institution’s tax exemption status. The court decision may be within the state of Pennsylvania or any other jurisdiction. Institutions are required to report all changes within ten days in writing to the Department.

Allinstitutionsareunderamandatorycontinuingobligation toreporttothePADepartmentofRevenueiftheorganizationiscurrentlybeing challenged by the Internal Revenue Service, the Commonwealth of Pennsylvania, a political subdivision, or any for profit entity. Institutions are required to report this information within ten days in writing to the Department.

All correspondence should be mailed to the following address:

PADepartment of Revenue

Bureau of Business Trust Fund Taxes

Miscellaneous Tax Division

PO BOX 280909

Harrisburg, PA17128-0909

SUBSECTION C – ORGANIZATION INFORMATION

All activities carried on by the institution for a period of three years should be reported. This explanation must contain a detailed description of how the beneficiaries are selected. Additional sheets can be attached to the application should the response require more room than the space allotted. If your by-laws or IRS Form 990 explain your organizational purpose in detail, those documents can be used to complete this section. Attach any additional documentation such as brochures or pamphlets that explain the institution’s purpose.

SUBSECTION D – AFFILIATE INFORMATION

In this section, indicate whether the institution is affiliated with another organization.Affiliate is defined as a domestic or foreign corporation, association, trust, or other organization that owns a 10% or greater interest in an institution of purely public charity. This definition also includes situations where an institution of purely public charity owns a 10% or greater interest in a domestic or foreign corporation, association, trust or other organization.

Please attach an organizational chart to the application.

For a parent institution to be considered as an “other nonprofit entity” for purposes of Act 55, all of its subsidiaries must first qualify as an Institution of Purely Public Charity. An organization seeking to qualify as an “other nonprofit entity” is only required to complete Section 1.

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SUBSECTION E – OFFICER INFORMATION

Enter the requested information for each officer. Additional sheets should be attached if the institution has more than four officers. This section must be completed even if the officers are not paid a salary from the organization. Organizations who complete IRS Form 990 may 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 taxes
		and other payroll deductions.
OTHER BENEFITS AND		List the benefits each officer receives in addition to their salary and include the value of
AMOUNTS OF EACH:		each benefit. Such benefits would include, but are not limited to, health insurance programs, life
		insurance, expense accounts, and automobile usage.
SUBSECTION F	–	SALARY INFORMATION

All organizations must complete this section. Organizations who file IRS Form 990 and complete Schedule A may substitute Schedule Aof the most recently completed return.

NAME:	List the names of the highest paid individuals within the organization, excluding the officers who were
	listed in Subsection E.
POSITION:	Indicate what position they hold within the institution, i.e., director, manager.
SALARY:	Indicate their current salary from the organization before taxes and other exclusions.
OTHER BENEFITS AND	List the benefits each individual receives in addition to their salary and include the value of each
AMOUNTS OF EACH:	benefit. Such benefits would include, but are not limited to, health insurance programs, life insurance,
	expense accounts, and automobile usage.

SECTION 2 – FINANCIAL INFORMATION

All institutions must complete Part 1 (Basic Questions) and all remaining parts as applicable. Emergency health and safety service institutions and religious organizations are only required to complete Part 1 (Basic Questions). Organizations engaging only in fundraising activities should complete Part 1 (Basic Questions) and Part 4 (Fundraising Activities). It is recommended that colleges and universities answer Part 1 (Basic Questions) as well as Part 2 (Recipient Information) questions 1, 4, and 5 to qualify. All other types of institutions should complete all of the parts as applicable. Institutions may answer “NO” or “N/A” – Not Applicable – to any question that does not pertain to their institution.

Institutions may either use the current year’s financial data or it may choose to average their financial information for the five most recently completed fiscal years. If the institution does average the financial information, all financial statements used in the calculations must be submitted with the application. Institutions electing to average financial data should indicate in the space provided the years from which they have used the data.

PART 1 – BASIC QUESTIONS

LINE 1 – INCOME – List each activity in which the institution receives revenue. This question must be completed by allinstitutions.

Acontribution includes any promise, grant, pledge or gift of money, property, goods, services, financial assistance or other similar remittance. It includes amounts received from individuals, trusts, corporations, estates, and foundations, or raised by an outside professional fund-raiser.

Afee-for-service payment is any payment received under any governmental program. This would include Medicare, Medicaid, Workers’Compensation, CHAMPUS, etc. Break out amounts according to the various programs.

LINE 2 – EXPENSES – List each expense the institution incurs as a result of its charitable activity. Examples would include salaries, supplies, equipment costs, postage and handling. All organizations must complete this question. If the institution completes IRS Form 990, the institution should attach a copy of the most recently completed year and may skip this question. The year of the IRS Form 990 must be identical to the year from which the remaining financial data is taken.

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LINE 3 – Avoluntary agreement is an agreement, contract or other arrangement whereby the institution is making contributions to a school district, municipality, or county government in lieu of taxes.The term voluntary agreement also includes the establishment of public service foundations by institutions of purely public charity.

If an institution has such an arrangement with local governments, indicate so in the space provided. If an institution has more than one agreement with different taxing jurisdictions, include the total number of agreements. Each agreement must be attached to the application.

LINE 4 – Each person who donates their time to the institution should be listed along with the reasonable number of hours per week and the number of weeks per year. The data must be from the same year as the financial data. Alternatively, the institution may list the number of individuals who contribute the same number of hours per week and weeks per year.Alisting by names and hours worked should be available for inspection by the Department if requested. For example, the institution may have 3 volunteers who each contribute 3 hours for 50 weeks and 5 volunteers who each contribute 5 hours per week for 26 weeks per year. The entry would appear as follows:

NAME OF INDIVIDUALOR NUMBER OF INDIVIDUALS	HOURS PER WEEK	WEEKS PER YEAR
3	3	50
5	5	26

LINE 5 – A. This figure represents the total number of individuals currently receiving goods or services from the institution. In calcu- lating the number of individuals for purposes of this section, educational institutions may include the number of full-time students as defined by the Department of Education. Supply any documentation that can support this figure. Examples of this would include children in a little league or patients seen by a hospital.

B.This figure represents total registered members of the organization.

LINE 6 – This figure represents the number of individuals who are receiving goods or services for which are free. The goods or services provided must be entirely free. Supply any documentation that can support this figure.

LINE 7 – This figure represents the number of individuals who pay a fee that is less than the cost the institution incurs in providing the goods or services. Regardless of the discount given, this figure should represent the total number of individuals who receive a discount. Do not include in the count the number of individuals who do not pay any fee.

LINE 8 – Check YES if any of the people who receive goods or services from the organization pay a fee that is equal to or greater than the cost of the goods or services provided to them.

LINE 9 – This question considers only those individuals who are receiving financial assistance from the institution. List the number of individuals who receive financial assistance, such as scholarships, grants, etc., from the institution.

LINE 10 – List the number who receive financial assistance of more than 10% of the cost of goods or services that are provided to them

Emergency Health and Safety Service Institutions and religious organizations should stop here.

PART 2 – RECIPIENT INFORMATION

LINE 1 – This figure represents the percentage of individuals who receive goods or services from the institution who pay a fee that is at least 10% lower than the cost of the goods or services they receive. Supply any documentation that can support this figure.

LINE 2 – This figure should represent the cost the institution incurs in providing community services. Supply any documentation that can support this figure.

LINE 3 – This figure should represent the payments the institution receives for providing community services. Supply any documentation that can support this figure.

LINE 4 – This figure should represent the cost the institution incurs in providing education and research programs. Supply any documentation that can support this figure.

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LINE 5 – This figure should represent the payments the institution receives for providing education and research programs. Supply any documentation that can support this figure.

LINE 6 – (A) The institution must indicate whether it supplies goods or services to individuals with mental retardation or to individuals who need mental health services.

(B)If the individual is mentally retarded or the recipient of mental health services, the institution must indicate whether it supplies an individual’s family or guardian in support of such goods or services.

(C) The institution must indicate whether it provides goods or services to individuals who are deemed dependent, neglected, or delinquent children.

If the response to either A, B, or C above is YES, then answer the next question. Otherwise, skip to the next Part. Check YES or NO as to whether any of the statutes or regulations apply to the organization.

PART 3 – GOODS OR SERVICES PROVIDED

LINE 1 – This figure is the full cost of providing goods or services for free.The institution cannot have received partial payments or even have attempted to collect payments. This figure is only the amounts the institution donates at 100%.

LINE 2 – This figure should include the loss that is incurred by the institution charging less than the full cost of goods or services the institution provides. This figure should not include bad debts or amounts deemed uncollectible. The cost of goods or services should only be those goods or services associated with the institution’s charitable purpose.The cost figure should include only actual cost incurred by the institution.

LINE 3 – The total amount of accounts deemed uncollectible should be included here. Uncollectible amounts are those that the institution has originally charged for, whether it be at full cost or at a discount, but for which the institution has not received payment. This figure is not the allowance for bad debts, or the bad debt expense, nor should it include any opportunity costs. Rather, it is only the actual cost of the goods or services provided for which the institution is unable to collect after reasonable and customary collection efforts have failed. If the institution did receive some payment, but not the full amount charged, include only what was uncollectible here.

LINE 4 – Check YES if the institution has a published, written policy that it provides goods or services to anyone who seeks them

regardless of their ability to pay. If the institution does have such a written policy, attach a copy to the application.

LINE 5 – Check YES if the institution has a published, written policy that it provides goods or services to people based upon their ability to pay. If the institution does have such a written policy, attach a copy to the application.

LINE 6 – Check YES if the institution has a written fee schedule that outlines how much an individual will pay based upon their income level. Acopy of the fee schedule must be enclosed with the application.

LINE 7 – If the goods that the individuals receive at no fee or at a reduced fee are of comparable quality and quantity to the goods or services offered at a higher cost, check YES.

LINE 8 – The institution should compute the cost of providing goods or services only to those individuals who are recipients of government programs. The government programs include, among other things, Medicare and Medicaid. Supply any documentation that can support this figure.

LINE 9 – If the institution provides goods or services for free or at a reduced rate to government agencies or individuals eligible for government programs, then check YES.

LINE 10 – If the institution provides goods or services to individuals who are eligible for government programs, check YES.

LINE 11 – This figure represents the cost of providing goods or services to individuals for whom the institution receives fee-for-service payments.Afee-for-service payment is any payment received under any governmental program.This would include Medicare, Medicaid, Workers’Compensation, CHAMPUS, etc. Supply any documentation that can support this figure. The amount the institution received from the government from fee-for-service payments should be listed under Part 1, question 1 (Income).

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LINE 12 – Check YES if the institution is licensed by the Department of Health or the Department of Public Welfare.

Attach a list showing the reasonable amount that the institution receives or donates to other charitable organizations in the form of contributions. The lists should be broken out according to each organization and the amount donated or received from each. Supply any documentation that can support this figure.

PART 4 – FUNDRAISING ACTIVITIES

LINE 1 – This question asks whether the institution operates to fund raise on behalf of, or supply grants to, another organization. This other organization must be an institution of purely public charity, an entity similarly recognized by another state or foreign jurisdiction, a qualifying religious organization, or a government agency. The institution must make an actual contribution of a substantial portion of the funds it raises to the organization. Alisting of the organizations who receive the contributions and the amount donated to each organization must accompany the application.

SUBSECTION D	–	AUTHORIZED SIGNATURE
SIGNATURE OF		The application must be signed by a corporate officer who is responsible for the information
CORPORATE OFFICER:		provided. Enter the title of the person who signed the form. If not incorporated, the application
		should be signed by a responsible party.
SOCIALSECURITYNUMBER:		The Social Security Number of the corporate officer or responsible party must be provided.
TYPE OR PRINT NAME:		Type or print name of the person who signed, the date the form was signed, and a daytime
		telephone number.
PREPARER’S NAME:		Type or print name of the preparer, the date, the preparer’s daytime telephone number, and title.
MAILCOMPLETED		PADEPARTMENT OF REVENUE
APPLICATION TO:		BUREAU OF BUSINESS TRUST FUND TAXES
		MISCELLANEOUS TAX DIVISION
		POBOX 280909

HARRISBURG, PA 17128-0909 (717) 783-5473

TT# 1-800-447-3020 (Services for taxpayers with special hearing and/or speaking needs).

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INSTITUTIONS SEEKING EXEMPTION FROM SALESAND USE TAX MUSTCOMPLETE THISAPPLICATION. SECTION 1 –- REGISTRATION MUST BE COMPLETED BYALLINSTITUTIONS. PLEASE FOLLOW THE INSTRUCTIONS CAREFULLYTO INSURE ALLPERTINENT INFORMATION AND SUPPORTING DOCUMENTATION ARE SUPPLIED.

CHECK THE APPROPRIATE BOX TO INDICATE THE REASON FOR THIS REGISTRATION.

NEW REGISTRATION

EXPIRED EXEMPTION STATUS

RENEWALUPDATE

REQUIRED DOCUMENTATION CHECKLIST

INCORPORATEDINSTITUTIONSMUSTPROVIDEACOPYOFTHEARTICLESOFINCORPORATIONSPECIFICALLYINCLUDINGAPROVISIONPROHIBITINGTHEUSE OFANYSURPLUS FUNDS FOR PRIVATE INUREMENT TOANYPERSON IN THE EVENT OFASALE OR DISSOLUTION OF THE INSTITUTION.

UNINCORPORATED INSTITUTIONS MUST PROVIDEACOPYOF THE BYLAWS ORANYGOVERNING DOCUMENT SPECIFICALLYINCLUDINGAPROVISION PRO- HIBITING THE USE OFANYSURPLUS FUNDS FOR PRIVATE INUREMENT TOANYPERSON IN THE EVENT OFASALE OR DISSOLUTION OF THE INSTITUTION.

ALL ORGANIZATIONS MUST PROVIDE A COPY OF THE MOST CURRENT FINANCIAL STATEMENT (NEW ORGANIZATIONS CAN SUBSTITUTE A PROPOSED BUDGET) INCLUDINGALLINCOMEAND EXPENSES LISTED BYSOURCEAND CATEGORY.

IF THE INSTITUTION HAS BEEN GRANTED EXEMPTION BYTHE INTERNALREVENUE SERVICE (IRS), PROVIDEACOPYOF THE DETERMINATION LETTER.

IF THE INSTITUTION FILES FORM 990, PROVIDEACOPYOF THE MOST RECENTLYCOMPLETED FORM WITH THEAPPLICATION.

SUBSECTION A	–	INSTITUTION INFORMATION
INSTITUTION LEGALNAME					FEDERALEMPLOYER IDENTIFICATION NUMBER (EIN) *
INSTITUTION TRADE NAME (IF DIFFERENTTHAN LEGALNAME)					INSTITUTION TELEPHONE NUMBER
INSTITUTION STREETADDRESS (do not use PO box)
CITY			STATE		ZIPCODE				DATE OF FIRSTOPERATIONS
LOCATION OF INSTITUTION RECORDS (street address)					CITY
COUNTY					STATE				ZIPCODE
INSTITUTION MAILINGADDRESS (if different than street address)			CITY		STATE				ZIPCODE
SUBSECTION B	–	FORM OF ORGANIZATION
CHECK THEAPPROPRIATE BOX:		CORPORATION		ASSOCIATION			OTHER
DATE OF INCORPORATION _________________________________________				STATE OF INCORPORATION
IS THE INSTITUTION ORGANIZED FOR PROFITOR NONPROFIT?				PROFIT			NONPROFIT
IF THE INSTITUTION QUALIFIES AS EXEMPTFROM TAXATION THROUGH THE INTERNAL
REVENUE SERVICE, INDICATE UNDER WHICH SECTION THE ORGANIZATION QUALIFIES:								501(C)(____________________)

*All organizations that have been granted 501(c) 3 tax exemption status by the United States Federal Government should supply their Federal EIN Number.

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APPLICATION FOR

PENNSYLVANIA

DEPARTMENT OF

SALES TAX EXEMPTION

EVENUE

SUBSECTION C

– ORGANIZATION INFORMATION

PROVIDE ADETAILED DESCRIPTION OF THE PAST, PRESENT, AND PLANNED FUTURE ACTIVITIES OF THE INSTITUTION FOR APERIOD OF THREE YEARS. INCLUDE ADESCRIPTION OF HOW BENEFICIARIES ARE SELECTED.

LIST EACH AFFILIATE, AND THEIR ADDRESS, THE DATE OF AFFILIATION/SUBSIDIARY, PERCENT OF OWNERSHIP IN EACH, THE TYPE OF INSTITUTION, THE RELATIONSHIP, AND WHETHER IT IS ORGANIZED AS A PROFIT OR NONPROFIT INSTITUTION. ATTACH ADDITIONAL SHEETS IF NECESSARYOR AN ORGANIZATIONALCHART.

SUBSECTION E – OFFICER INFORMATION

THIS SECTION MUST BE COMPLETED IN FULL BY EVERY INSTITUTION EVEN IF THE INSTITUTION DOES NOT COMPENSATE ITS OFFICERS. THE ANNUALCOMPENSATION SHOULD INCLUDE THE OFFICER’S SALARYFROM THE INSTITUTION, CONTRIBUTIONS MADE ON THE OFFICER’S BEHALF TO EMPLOYEE BENEFIT PROGRAMS AND DEFERRED COMPENSATION, EXPENSE ACCOUNT, AND ANY OTHER FORM OF COMPENSATION. ATTACH ADDITIONALSHEETS IF NECESSARY. IRS FORM 990 MAYBE SUBSTITUTED.

LASTNAME	FIRSTNAME	TITLE	ANNUALCOMPENSATION
OTHER BENEFITS AND AMOUNTS OF EACH
LASTNAME	FIRSTNAME	TITLE	ANNUALCOMPENSATION
OTHER BENEFITS AND AMOUNTS OF EACH
LASTNAME	FIRSTNAME	TITLE	ANNUALCOMPENSATION
OTHER BENEFITS AND AMOUNTS OF EACH
LASTNAME	FIRSTNAME	TITLE	ANNUALCOMPENSATION
OTHER BENEFITS AND AMOUNTS OF EACH

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APPLICATION FOR

PENNSYLVANIA

DEPARTMENT OF

SALES TAX EXEMPTION

EVENUE

SUBSECTION F – SALARY INFORMATION All organizations must complete this information.

LISTPOSITION, SALARY,AND OTHER COMPENSATION, INCLUDING BENEFITS, OF THE FOUR HIGHESTPAID INDIVIDUALS. DO NOTREPEAT THOSE OFFICERS LISTED IN SUBSECTION E (OFFICER INFORMATION). INDICATE IN THE SPACE ALLOTTED BELOW A STATEMENT INDI- CATING THE BASIS OF COMPENSATION. IF THE INSTITUTIONIS COMPRISED ONLYOF VOLUNTEERS, SKIPTHIS SECTION BYWRITING “NOT APPLICABLE”. IF SCHEDULE AIS COMPLETED, IRS FORM 990 SCHEDULE AMAYBE SUBSTITUTED.

LAST NAME	FIRST NAME	POSITION	SALARY
OTHER BENEFITS AND AMOUNTS OF EACH
LASTNAME	FIRSTNAME	POSITION	SALARY
OTHER BENEFITS AND AMOUNTS OF EACH
LASTNAME	FIRSTNAME	POSITION	SALARY
OTHER BENEFITS AND AMOUNTS OF EACH
LASTNAME	FIRSTNAME	POSITION	SALARY
OTHER BENEFITS AND AMOUNTS OF EACH

SECTION 2 – FINANCIAL DATA

PLEASE REFER TO THE INSTRUCTIONS BEFORE COMPLETING THIS SECTION. ALLINSTITUTIONS MUSTCOMPLETE SECTION 1.

INDICATE THE YEAR FROM WHICH FINANCIALDATAWAS USED:

PART 1 – BASIC QUESTIONS

(1)INCOME – LISTALLOF THE SOURCES OF INCOME, INCLUDING CONTRIBUTIONS, RECEIVED AS PART OF THE INSTITUTION’S CHARI- TABLE PURPOSE. EXAMPLE CATEGORIES ARE LISTED. ADDITIONALSOURCES SHOULD BE LISTED AND IDENTIFIED UNDER ‘OTHER’. ATTACH ADDITIONALSHEETS IF NECESSARY.

ACTIVITY	DOLLAR AMOUNT

CONTRIBUTIONS & DONATIONS

FEES RECEIVED FOR GOODS OR SERVICES

FEE-FOR-SERVICE PAYMENTS FOR ANYGOVERNMENTALPROGRAMS

GOVERNMENTSUPPORT(ie. GRANTS, FUNDING, etc.)

OTHER, LIST:

TOTAL REVENUE

(INCLUDINGAMOUNTSLISTED ONSEPARATESHEETS)

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APPLICATION FOR

PENNSYLVANIA

DEPARTMENT OF

SALES TAX EXEMPTION

EVENUE

(2)EXPENSES – LIST THE EXPENSES DIRECTLY RELATED TO THE INSTITUTION’S CHARITABLE PURPOSE AND THEIR RESPECTIVE AMOUNTS. ATTACH ADDITIONAL SHEETS TO THE APPLICATION. (NOTE: ANY EXPENSES NOT INCLUDED IN THIS SECTION MAY BE SUBJECTTO ASALES OR USE TAX.) IRS FORM 990 MAYBE SUBSTITUTED.

ACTIVITY	DOLLAR AMOUNT

TOTAL EXPENSES

(INCLUDINGAMOUNTSLISTED ONSEPARATESHEETS)

(3)DOES THE INSTITUTION HAVE AVOLUNTARYAGREEMENT(i.e. PILOT, SILOT, etc.) WITH APOLITICAL

SUBDIVISION? ATTACH ACOPYOF EACH AGREEMENTWITH THE APPLICATION.

YES

NO

(4)VOLUNTEERS – THE INSTITUTION MAY ELECT TO LIST THE NAME OF EACH VOLUNTEER, ALONG WITH THE NUMBER OF HOURS WORKED EACH WEEK AND THE NUMBER OF WEEKS VOLUNTEERED FOR THE YEAR. ALTERNATIVELY, THE INSTITUTION MAYBREAK OUTTHEIR LISTACCORDING TO THE NUMBER OF VOLUNTEERS WHO CONTRIBUTE THE SAME NUMBER OF HOURS EACH WEEKAND WEEKS EACH YEAR. ALISTING BY NAMES AND HOURS WORKED SHOULD BE AVAILABLE FOR INSPECTION BYTHE DEPARTMENT IF REQUESTED. ATTACH ADDITIONALSHEETS AS NEEDED.

YEAR FROM WHICH VOLUNTEER DATAWAS GATHERED:

NAME OF INDIVIDUALOR NUMBER OF INDIVIDUALS	HOURS PER WEEK	WEEKS PER YEAR

(5)A. HOW MANYPEOPLE RECEIVE GOODS OR SERVICES FROM THE INSTITUTION? B. HOW MANYREGISTERED MEMBERS ARE IN YOUR ORGANIZATION/CHURCH?

(6)HOW MANYPEOPLE RECEIVE THE GOODS OR SERVICES FOR FREE?

(7)HOW MANYPEOPLE PAYAREDUCED FEE FOR THE GOODS OR SERVICES?

(8)DO ANYOF THE PEOPLE RECEIVING GOODS OR SERVICES PAYAFEE WHICH IS EQUAL

TO OR GREATER THAN THE COSTOF THE GOODS OR SERVICES PROVIDED TO THEM?

YES

NO

(9)WHATNUMBER OF INDIVIDUALS RECEIVE FINANCIALASSISTANCE FROM THE INSTITUTION?

(10)AFTER SUBTRACTING THE FINANCIALASSISTANCE GRANTED BYTHE INSTITUTION, HOW MANYINDIVIDUALS PAID AFEE 90% OR LESS OF THE COSTOF THE GOODS OR SERVICES PROVIDED TO THEM?

Emergency Health and Safety Service Institutions and religious organizations should stop here and turn to page 12 and complete theAuthorized Signature.

PART 2 – RECIPIENT INFORMATION

(1)WHATPERCENTAGE OF INDIVIDUALS RECEIVING GOODS OR SERVICES FROM THE INSTITUTION RECEIVE AREDUCTION IN FEES OF ATLEAST10% OF THE COSTOF THE GOODS OR SERVICES PROVIDED TO THEM?

(2)WHATIS THE COSTOF PROVIDING COMMUNITYSERVICES PROVIDED BYOR PARTICIPATED IN BYTHE INSTITUTION? ATTACH ACOPYOF SUPPORTING DOCUMENTATION TO

THE APPLICATION.

(3)WHATAMOUNTDOES THE INSTITUTION RECEIVE AS PAYMENTS TO SUPPORTSUCH COMMUNITYSERVICES? ATTACH ACOPYOF SUPPORTING DOCUMENTATION TO THE APPLICATION.

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APPLICATION FOR

PENNSYLVANIA

DEPARTMENT OF

SALES TAX EXEMPTION

EVENUE