Sample Federal excise tax exemption certificate

Date:_____________ 

I certify that I, am the  __________ (Title), of __________________ (Name of company or organization) and that communication services provided by _______________________ ( Name of Phone company), are exempt from tax under section 4253 of the Internal Revenue Code.

□ (c) International Organization 
□ (h) Nonprofit Hospitals
□ (i) State and Local Governments
□ (j) Nonprofit Educational Organizations
□ Other                    


Signature of Officer or Employee    ___________________________
Street Address                               ___________________________
City, / State, Zip                            ___________________________
Employer Identification Number     ___________________________
 

Penalty for fraudulent use, $10,000 or imprisonment, or both.      

Regulation 49.4253-3
Internal Revenue Service Code Section 4253(k)(1) IN GENERAL.- In order to claim a exemption under subsection (c), (h), (I), or (j), a person shall provide to the provider of communications services a statement (in such form and manner as the Secretary may provide) certifying that such person is entitled to such exemption.

(2) DURATION OF CERTIFICATE.- Any statement provided under paragraph (1) shall remain in effect until—(A) the provider of communications services has actual knowledge that the information provided in such statement is false, or (B) such provider is notified by the Secretary that the provider of the statement is no longer entitle to an exemption described in paragraph (1).  If any information provided in such statement is no longer accurate, the person providing such statement shall inform the provider of communications services within 30 days of any change of information.