Indiana Department of Revenue
          NP-20A
       State Form 51064                                     Nonprofit Application for 
          (R5 / 8-22)
                                                              Sales Tax Exemption
                                                                      NO FEE REQUIRED.

 Part I
 Full Name of Organization                                                                  This Area for Department Use Only
                                                                                                                                                     Type

 Street Address

 City, State, ZIP Code                             County
                                                                          Indiana Taxpayer Identification Number  Federal Employer Identification Number
 Date Incorporated         Enter the Month Your
 or Formed:                Accounting Period Ends:
 What is the predominant purpose of your organization?

 Part   II
 1. Indicate type of qualifying organization named in I.C. 6-2.5-5-21 (Check only one box in A, B, or C).

          A.   Organized specifically as a:
                □ (1)  Church                 □ (3) Monastery/Convent               □ (5)  Labor Union             □ (7) Veteran’s Group         
                □ (2) Hospital                □ (4)  Parochial School               □ (6)  Pension Trust

          B.   Organized and operated for one of the following reasons:
                □ (1)  Religious              □ (3)  Scientific                     □ (5)  Educational             □ (7)  Student Co-operative Housing
                □ (2)  Charitable             □ (4)  Literary                       □ (6)  Civic 

          C.  Organized and operated as one of the following entities:
                □ (1)  Fraternal (including fraternal                               □ (2)  Business League 
                           beneficiary societies)                                   □ (3)  Business Association
 2. Do you sell or rent tangible personal property or have other receipts that are subject to sales tax? □ □ No   Yes    

 3. Is this organization a local affiliate of a national or parent organization? □ □ No     Yes – If so enter name and address of national or parent 
                                                                                            organization.

 4. Has this organization previously applied for Indiana exempt status?          □ No    □ Yes – If so, please indicate previous registration number.

    IMPORTANT – Attach the following document.
    Copy of federal determination letter (ruling from the Internal Revenue Service) showing the section of the Internal Revenue Code exemption 
    from federal tax has been granted.  To obtain a copy of federal determination letter or to apply for federal exemption, contact the IRS at: 
    1-877-829-5500

    Mail To:
    Indiana Department of Revenue
    P.O. Box 1261
    Indianapolis, IN 46207-1261
    (317) 232-0129
 I declare under the penalties of perjury that I am authorized to sign this application on behalf of the above organization and I have examined this 
 application, including the accompanying statements, and to the best of my knowledge it is true, correct and complete.

 Name of Person(s) to Contact                                   Daytime Telephone Number(s)                      Email Address

 Signature                                                      Title                                            Date Signed