Department of Taxation and Finance

                     New York State and Local Sales and Use Tax                                                          ST-119.4(7/17)
                     Application for an Exempt Organization
                     Certificate - Information Authorization

This Information Authorization is valid only for appointing a representative to receive oral or written communications in conjunction with 
the review of your organization’s application for an Exempt Organization Certificate by the Sales Tax Exempt Organizations Unit. It may 
not be used to protest the denial of an application for an Exempt Organization Certificate or to request a hearing before the Division 
of Tax Appeals on such a denial since your appointed representative may not be a qualified representative for these purposes. Your 
organization must use Form POA‑1, Power of Attorney, in these instances.

Type or print.
Organization                                                                Approved representative
Organization’s name                                                         Representative’s name

Mailing address (number and street or PO Box)                               Mailing address (number and street or PO Box)

City and state                                                              City and state

ZIP code                                                                    ZIP code

State the relationship of the appointed representative to your organization Telephone number

                                                                            (     )
                                                                            Email address

The organization named above appoints the person named above as its representative for the sole purpose of receiving all oral and 
written communications and documents in connection with the organization’s application for exemption from sales and use taxes under 
Tax Law section 1116(a).
By signing below, I certify, under penalty of perjury, that I am the officer, partner (except a limited partner), member or manager of a 
limited liability company, or fiduciary acting on behalf of the organization listed above, and that I have the authority to execute this 
Application for an Exempt Organization Certificate – Information Authorization.

Officer or trustee
Printed name                                               Title                                   Telephone number

                                                                                                   (     )
Signature                                                                                            Date

Mail your completed application to:
NYS TAX DEPARTMENT
SALES TAX EXEMPT ORGANIZATIONS SECTION
W A HARRIMAN CAMPUS
ALBANY, NY 12227-9154

If not using U.S. Mail, see Publication 55, Designated Private Delivery Services.