DR 0716 (08/30/13) 
COLORADO DEPARTMENT OF REVENUE                                                              *130716==19999*
Sales Tax Accounting Section, Room 208
PO Box 17087
Denver, CO 80217-0087
www.TaxColorado.com
                                           Statement of Nonprofit  
                     Church, Synagogue, or Organization
Name of Organization

Location Address                           City                                                                      State Zip

Mailing Address                            City                                                                      State Zip

The above listed organization applying for a sales tax exemption certificate with the State of Colorado hereby attests that:
  I.   No part of the net earning inures to the benefit of any private member or individual;
  II.  No substantial part of the activities involves the carrying on of propaganda or otherwise attempting to influence  
       legislation;
  III. The organization does not participate in, or intervene in (including the publishing or distribution of statements), any 
       political campaign on behalf of any candidate for public office.
  IV.  The organization does not limit its deeds and gifts to its members or beneficiaries only;
  V.   The funds received by the organization are not solely dependent on required payments (generally, dues) of its  
       members.
 VI.   File this form with the DR 0715 and supporting documents listed under “charitable.”

Under penalties of perjury, I swear or affirm the information on this form is true and correct as to every material  
matter.
Authorized Signature (Director or Officer) Title                                                                     Date (MM/DD/YY)

(For churches or Synagogues, this would be the Pastor, Rabbi, Priest, Deacon, Bishop, Cardinal, Treasurer or Trustee)