APPLICATION FOR SALES TAX EXEMPTION CERTIFICATE
                            OFFICE OF STATE TAX COMMISSIONER
                            SFN 21919 (6-2021)

See the Exempt Organization guideline for more detail about organizatons that qualify for a sales tax exemption on 
purchase transactions.

This application should be filed only by federal, state, local or tribal governments; federal corporations; schools; hospitals, 
nursing homes, intermediate care facilities, basic care facilities, residential end-of-life facilities,and emergency medical 
service providers licensed by the State Department of Health; voluntary health associations recognized by the National 
Health Council; and assisted living facilities licensed by the Department of Human Services; and certain senior citizen 
organizations.
Organization Name                                                                                      Federal Employee Identification Number

Email Address                                                                                          Telephone Number

Street Address                                                     City                          State ZIP Code

Mailing Address                                                    City                          State ZIP Code

Type of organization (Fill one)
  Federal Government           State         County or Township               City            Native American Tribal Governments
  Public or Private School, College or University                               Voluntary Health Association
  Intermediate Care Facility (North Dakota Department of Health license number _____________________________)
  Assisted Living Facility (North Dakota Human Services license number _____________________________)
  Basic Care Facility (North Dakota Department of Health license number _____________________________)
  Emergency Medical Services Provider (North Dakota Department of Health license number _____________________________)
  Hospital (North Dakota Department of Health license number _____________________________)
  Skilled Nursing Facility (North Dakota Department of Health license number _____________________________)
  Residential End-of-Life Facility (North Dakota Department of Health license number _____________________________)
  Senior Citizen Organization, include the following documentation:
        1.  Proof of 501(c)(3) status designated by IRS;
        2.  Proof of North Dakota Secretary of State Charitable Organization designation;
        3. Proof of one (1) of the following: a) Contract with North Dakota Department of Human Services to provide services through 
           Aging Services Division; OR, b) Proof of receiving grant funds through the North Dakota Department of Transportation.
Provide explanation of primary function of organization _________________________________________________________________
 _____________________________________________________________________________________________________________

Does the organization hold a sales and use tax permit?    Yes             No

Does the organization make any retail sales?    Yes      No
Authorized Purchasing Agent                                        Title                               Telephone number

I certify that the above statements are correct to the best of my knowledge and belief and that I am authorized to sign this application.
Signature                                                                                   Title

Print Name                                                                                             Date

Important:  The Certificate of Exemption, if granted, applies to purchases only. It does not apply to the sale of tangible personal property. As 
soon as your application is approved, a Certificate will be mailed. This certificate must be retained by you and a copy of your certificate must 
be furnished to all suppliers or retailers at the time of purchase.
                                                 PRIVACY ACT NOTIFICATION
In compliance with the Privacy Act of 1974, disclosure of a social security number or Federal Employer Identification Number (FEIN) on this form is required 
under N.D.C.C. §§ 57-01-15, and will be used for tax reporting, identification, and administration of North Dakota tax laws. Disclosure is mandatory. Failure to 
provide the social security number or FEIN may delay or prevent the processing of this form.
                 Telephone number:  701-328-1246                         Email: salestax@nd.gov
                 Fax number:   701-328-0336                              Website: www.nd.gov/tax