Pennsylvania Institution of Purely Public Charity Renewal Affidavit

Institution of Purely Public Charity Renewal Affidavit
Institution of Purely Public Charity Renewal Affidavit (REV-956)
(TR) 01-20

REV-956

OFFICIAL USE ONLY

BuReau of ReGISTRaTIoN
aND TaXPaYeR MaNaGeMeNT
Po BoX 280901
HaRRISBuRG Pa 17128-0901

INSTITUTION OF PURELY
PUBLIC CHARITY RENEWAL
AFFIDAVIT

Use this form to renew your existing Sales Tax Exemption Certificate.
INSTRUCTIONS:
This form must accompany the completed Application for Sales Tax Exemption, REV-72 in order to renew the Sales Tax Exemption Certificate.
An institution of purely public charity applying for a renewal of sales tax exempt status that completes this affidavit will not be required to submit articles
of incorporation, by-laws or other documents as otherwise directed on the Application for Sales Tax Exemption, REV-72.
If the organization is incorporated, the affidavit must be signed by a corporate officer of the organization. If not incorporated, the affidavit must be signed
by a responsible party of the organization.
Fax the completed form, along with the REV-72 to (717) 787-3708 or
Email to [email protected].

SECTION I
ORGANIZATION INFORMATION
START Name of Organization (as reported on the Application for Sales Tax Exemption, REV-72.)

Exemption Number

➜

75Mailing Address
City

State

ZIP Code

Telephone Number

Select one of the following that apply and complete the information:

MM/DD/YYYY

Incorporated
Unincorporated

Date of Incorporation Have the articles of incorporation been amended in the last 5 years?
No
Yes*, Provide last amendment date
Date of Formation

MM/DD/YYYY

Have the by-laws been amended in the last 5 years?
No
Yes*, Provide last amendment date

MM/DD/YYYY

*Important: If the institution has adopted any governance changes after the original filing of the Application for Sales Tax Exemption, REV-72, you
must provide a copy of any amendments along with a detailed explanation of how such changes affect the institution.

SECTION II

CORPORATE OFFICER/RESPONSIBLE PARTY INFORMATION

Name

Title

Mailing Address
City

SECTION III

State

ZIP Code

Telephone Number

CERTIFICATION

Under penalties of perjury, I declare I have examined the above statements and any accompanying documents, and to the best of my knowledge and
belief, all facts relating to this matter contained therein, are true, correct and complete.
Signature

Date

MM/DD/YYYY

SIGN AFTER PRINTING
Notarization:
Subscribed and sworn before me this

day of

20

.
My commission expires

, 20

.

SIGN AFTER PRINTING
Do not mark below this line.

Reset Entire Form

Signature of Notary Public

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