PDF document
- 1 -
                                  Application for Certificate of Tax Exemption                                                     City of Westminster
                                                                                                                                   Department of Finance
                                                Return this completed form with the required deliverables.                         Sales Tax Division
                                                       Please Type or Print Clearly
                                1) Legal Name of Organization:                                                                     CITY USE ONLY

                                2) Trade Name (DBA) of Organization (if any):                                                  Date Received:

                                3) Mailing Address:                                                                            City Account:

                                4) City:                                              5) State:        6) Zip:                 Disposition:

                                E-mail Address:

       7) Type of Organization:      Charitable Organization          Qualified Hospital Organization          Government
Charitable Organizations: Answer the questions on the following lines in detail, except line 13. When possible, include literature, articles, brochures, policies
& procedures, or other organizational documents supporting these responses with the required deliverables. Include additional sheets if necessary. Sign the
application, and enclose deliverable items a, b, and d through h with this form.
Qualified Hospital Organizations: Do not complete lines 8 through 12. Complete line 13. Include additional sheets if necessary. Sign the application, and
enclose deliverables a, b, and c with this form.
Governments: Do not complete lines 8 through 13. Sign the application, and enclose deliverable b with this form.
8) List the organization's mission or purpose.

9) Outline whom the organization serves including any qualifications for membership or conditions for receiving services.

10) Describe the primary activities of the organization including any goods or services provided.

11) Describe the sources of program service revenues (excluding contributions and fundraising events).

12) Describe how the organization and its activities lessen the burdens of government.

13) Qualified hospital organizations include certain affiliated entities. If the legal entity listed on line 1 is not the legal entity that holds the accompanying general
hospital license, describe the relationship between the applying entity and the entity that holds the general hospital license.

Submit copies of the following information to this application. Deliverables will not be returned. Incomplete applications may not be reviewed.
a. Internal Revenue Service determination letter recognizing the organization as exempt from Federal income tax under § 501(c)(3)
b. Certificate of Exemption issued by the Colorado Department of Revenue
c. General Hospital License issued by the Colorado Department of Public Health & Environment
d. Articles of Incorporation
e. Bylaws of the Organization
f. Most recent Federal Return of Organization Exempt from Income Tax (I.R.S. form 990)
g. Most recent financial statements including detail of revenue and income sources
h. Brochures, marketing literature, policies and procedures, or other forms of documentation supporting claim for exemption
                                Under penalty of perjury, I declare that I have examined this Application for Certificate of Tax Exemption   and that it is true
                                and correct to the best of my knowledge and belief.

Applicant
                                        Signature                                                                              Date
Signature

                                        Printed Name                                  Title                                    Phone No.
Return completed form with deliverables to:Westminster Department of Finance   Sales Tax Division   4800 W 92nd Avenue   Westminster,     CO 80031



- 2 -
        Instructions for Application for Certificate of Tax Exemption 

General Instructions                                                    department, division, agency, instrumentality, or political 
                                                                        subdivision  of the United States,  the State of Colorado, or 
                                                                        another state. 
Purpose of Form                                                          
                                                                        Line 8 – Mission or purpose. Charitable organizations must 
This form is used for organizations to request review of their          list  the  stated  mission  or  purpose  of  the  organization.  If  the 
activities  to  determine  if  they  qualify  for  exemption  from  tax mission or purpose is stated in the articles of incorporation or 
under various provisions of the Westminster Municipal Code              bylaws,  simply  list  the  name  of  the  document  and  the 
(“Code”).  Because Westminster  laws  regarding  exemption              section(s) in which the mission or purpose appears. 
differ from other taxing authorities, tax exempt entities may be         
required to present evidence of exemption specific to the City.         Line  9  –  Persons  served.  Charitable  organizations  must 
Governments  may also apply in order to  avoid  disputes                outline all persons, groups, or other organizations served by 
regarding their tax exempt status.                                      the  applicant  organization.  Include descriptions  of the 
                                                                        relationship that exists, if any, between the organization and 
Not all organizations exempt from Federal income tax under §            those served. State whether, for example, all persons served 
501(c)(3) will qualify for exemption  under  Westminster’s tax          are members or clients  of the organization.  If the 
code. Refer to Tax Compliance Guide        topic 307 for  a             organizations serves only members, describe or attach  the 
discussion of Westminster’s requirements.                               qualifications  of membership.  If  the  organization  serves 
                                                                        specific clients, the intake or client acceptance policy should 
After review of the application, a written determination will be        also be provided. 
issued.  If approved, a Certificate of Tax Exemption will                
accompany the determination.                                            Line 10 – Primary activities. Charitable organizations must 
                                                                        describe the  primary activities  of the organization.  Discuss 
Reminders                                                               how these activities serve the physical, mental, and/or 
                                                                        spiritual needs of the persons served by the organization. 
Enclose  all  requested  deliverables. Documentation  is  the            
foundation  of  the  request.  Include  all  documentation              Line 11  –  Program service revenues.  Charitable 
necessary to support the claim that the organization qualifies          organizations  must detail  the  fees,  charges,  or  other 
for exemption under the Code.  The  deliverables that are               consideration received  in exchange for  goods or  services, if 
required to be submitted  follow  line 13.  Incomplete                  any. Include all fees or charges regardless of whether or not 
applications  may  not  be  reviewed.  Additional  documentation        they are collected directly  from the  person  or persons 
may be requested if necessary.                                          benefiting  from  the  good  or  service.  Do  not  include  grants, 
                                                                        donations,  or other voluntary contributions which would 
Other licenses required. Exempt organizations may need to               constitute a gift.  Do not include fees  or admissions to 
apply for business licenses or other licenses required by Title         fundraising events.  The collection of fees does not 
V of the Code despite their tax exempt status. Refer to Title V         automatically disqualify an organization from exemption. 
of the Code for further information.                                     
                                                                        Line  12  –  Lessening  the  burdens  of  government. 
Exempt organizations are not excused from collection. A                 Charitable  organizations  must  describe how the activities  of 
Certificate  of Exemption only applies to  certain qualifying           the organization lessen the burdens of government. Note that 
direct  purchases made by the organization. Exempt                      it is not a requirement for exemption that  the organization 
organizations must collect tax on sales made to the public.             relieve a burden of the City of Westminster specifically. 
                                                                         
Exemption does not apply to construction materials.          If         Line 13 – Qualifying Affiliated Entities. “Qualified hospital 
granted,  exemption does  not extend  to construction                   organizations” include 501(c)(3) general hospitals, as well as 
contractors working for exempt organizations nor does it apply          certain affiliated entities  more particularly described in the 
to construction materials used in jobs requiring a City building        definition of the  same under §  4-1-1 of the Code. If the 
permit.                                                                 applicant  differs  from  the  legal  entity  listed  on  the  enclosed 
                                                                        general hospital license, the  applicant must  describe  its 
Signature  required.  The  person  completing  the  application         relationship to the general hospital licensee so that it may be 
on behalf of the organization must sign and date the form at            evaluated as a qualifying affiliate. 
the bottom. A printed name and title is also required. Forms             
without a signature will be returned.                                   Deliverables  –  The  list  of  deliverables  supporting  an 
                                                                        organization’s  claim  of  exempt  status  must  be  enclosed  as 
                                                                        follows: 
Specific Instructions                                                    
                                                                         Charitable Organizations: Items a, b, d, e, f, g, & h. 
Lines 1  thru 6  –  Organization Information.  Print the legal           Qualified Hospital Organizations: Items a, b, & c. 
name, the trade or other name the organization is known as,              Governments: Item b. 
and the mailing address of the organization.                             
                                                                        Signature – After reviewing the form for accuracy, sign and 
Line  7  –  Type of Organization.  Check the box that best              date the form. Print your name and title below your signature. 
represents  the  type  of  organization.  This  selection  does  not    Return the form  to the  Westminster Department of  Finance 
necessarily preclude application/approval under another type.           along with the required deliverables. 
Do  not  select  government  unless  the  applicant is  a 






PDF file checksum: 1643611536

(Plugin #1/9.12/13.0)