CERTIFICATE OF EXEMPTION FROM FEDERAL EXCISE TAX
ON CHARGES FOR COMMUNICATION SERVICES
The undersigned represents he/she is authorized to execute this certificate and hereby claims exemption from taxes imposed by
Section
4251 of the Internal Revenue Code under the following provisions. (Check applicable section and provide information where
required.)
A. ( ) RESELLER OF COMMUNICATION SERVICES
The undersigned certifies the communication services furnished by the telephone company will be used exclusively in the rendering
of a
communication service upon which tax is imposed by Section 4251 of the Internal Revenue Code. It is understood that no tax will be
collected by the telephone company on charges for said services and it will be the responsibility of the undersigned to collect such
tax as
may be due from its members and to remit it to the Internal Revenue Service.
B. ( ) GOVERNMENTAL ORGANIZATIONS
The undersigned claims exemption from the tax imposed on all communication services billed to or to be billed the undersigned. The
undersigned certifies such exemptions are allowable by law because such service is being and will be furnished to and charges will
be paid
from the funds of (check one):
( ) The United States (Section 4293)
( ) A state or political subdivision thereof (including county, city, village or township governmental bodies) (Section
4253(i))
( ) An Indian tribal government or political subdivision (Section 4253(i); Section 7871)
( ) A public International Organization (Section 4253(c ); Section 7701(a)(18) made tax exempt by Presidential Executive
Order No. ____________________
( ) An organization created and specifically designed tax exempt by Act of Congress. Public Law No. ___________
( ) A quasi-governmental organization, performing the civic function of __________________________ paid from the
funds of
_______________________________ (Name of Exempt Organization)
( ) A public school or school administration office (Section 4253(i))
C. ( ) AMB