Indiana Department of Revenue NP-20A Nonprofit Application for Sales Tax Exemption State Form 51064 (R/3-09) NO FEE REQUIRED. Part I Full Name of Organization _______________________________________ This Area for Department Use Only Type Street Address City, State, Zip Code County Date Incorporated Enter the Month Your or Formed: Accounting Period Ends: Indiana Taxpayer Identification Number Federal Identification Number What is the predominant purpose of your organization? Part II 1. Indicate type of qualifying organization named in I.C. 6-2.5-5-21 (Check only one box in A, B, or C). A. Organized specifically as a:  (5) Departmental Use Only  (7) Pension Trust  (1) Church  (3) Monastery/Convent  (6) Labor Union  (8) Veteran's Group  (2) Hospital  (4) Parochial School B. Organized and operated for one of the following reasons:  (3) Scientific  (5) Educational  (1) Religious  (4) Literary  (6) Civic  (2) Charitable C. Organized and operated as one of the following entities:  (7) VEBA  (8) Student Co-operative Housing  (1) Fraternal (including fraternal  (2) Departmental Use Only  (4) Business Association  (3) Business League 2. Does your organization sell or rent personal property for more than 30 days in a calendar year?  No  Yes beneficiary societies) 3. Is this organization a local affiliate of a national or parent organization?  No  Yes--If so enter name and address of national or parent organization. 4. Has this organization previously applied for Indiana exempt status?  No  Yes--If so, please indicate previous registration number. IMPORTANT --Attach the following documents. Copy of federal determination letter (ruling from the Internal Revenue Service) showing the section of the Internal Revenue Code exemption from federal tax has been granted. To obtain a copy of federal determination letter or to apply for federal exemption, contact the IRS at: 1-877-829-5500 Mail To: Indiana Department of Revenue Tax Administration/Support 100 N. Senate Ave. Room N203 MS105 Indianapolis, IN 46204 (317) 232-2045 I declare under the penalties of perjury that I am authorized to sign this application on behalf of the above organization and I have examined this application, including the accompanying statements, and to the best of my knowledge it is true, correct and complete. Name of Person(s) to Contact Signature Daytime Telephone Number(s) Title Email Address Date Signed American LegalNet, Inc. www.FormsWorkflow.com