Form ST: EX-A 3 Application for State Utility/Mobile Communication Services Tax Certificate of Exemption - Alabama

Form ST: EX-A3 is a Alabama Department of Revenue form also known as the "Application For State Utility/mobile Communication Services Tax Certificate Of Exemption". The latest edition of the form was released in September 1, 2018 and is available for digital filing.

Download a fillable PDF version of the Form ST: EX-A3 down below or find it on Alabama Department of Revenue Forms website.

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ST: EX-A3
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Application for State utility/mobile Communication
Services tax Certificate of exemption
Pursuant To Rule 810-6-5-.26.05
An Alabama utility/mobile Communication Services tax Certificate of exemption shall be used by persons, firms, or
corporations coming under the provisions of the utility Gross receipts tax and mobile Communication Services tax
statutes who are not required to have a utility tax and/or mobile communication services tax license.
PLEASE COMPLETE EACH LINE APPLICABLE TO YOUR BUSINESS. A UTILITY/MOBILE COMMUNICATION
SERVICES TAX CERTIFICATE OF EXEMPTION CANNOT BE ISSUED UNTIL THIS APPLICATION IS PROPERLY
COMPLETED.
1. federal employer identification number (fein) _______________________ 2. business telephone (_____)_____________
3. ____________________________________________________ _______________________________________________________
Legal name of person(s), firm, corporation, association, partnership making application.
Trade name
4. mailing address of home office _______________________________________________________________________________
P. O. Box or Street No. or R.F.D.
___________________________________________________________________________________________________________
City
County
State
Zip Code
5. number of businesses in Alabama __________ location__________________________________________________________
City
Street or Hwy. No.
County
location must be exact street number or, if on a highway or rural route, give details of the location. if more than one
location, please attach a schedule._____________________________________________________________________________
6. email (for renewal notification): ______________________________________________________________________________
7. Kind or class of business _____________________________________________________________________________________
wholesaler, reseller, broker, etc.
8. Kind of service(s) to be purchased tax-exempt:
electricity
Domestic Water
natural Gas
telegraph
telephone
mobile Communication
9. REASON(S) EXEMPTION CLAIMED ________________________________________________________________________
10. form of ownership:
individual  
partnership  
Corporation  
multi member llC  
Single member llC
if applicant is a corporation, a copy of the certified certificate of incorporation, amended certificate of incorporation, cer-
tificate of authority, or articles of incorporation should be attached. if the applicant is a limited liability company or a lim-
ited liability partnership, a copy of the certified articles of organization should be attached.
11. ownership information:
Corporations – give name, title, home address, and Social Security number of each officer.
partnerships/llp’s – give name, home address, Social Security number or fein of each partner, and valid Alabama
driver’s license or other acceptable citizenship documentation.
Sole proprietorships – give name, home address, Social Security number of owner, and valid Alabama driver’s license
or other acceptable citizenship documentation.
llC – give name, home address, and Social Security number or fein of each member. (valid Alabama driver’s license
or other acceptable citizenship documentation is required for single member llCs.)
llp – give name, title, home address, and Social Security number of each officer.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Signed _______________________________________________
Signed _______________________________________________
title __________________________ Date __________________
title __________________________ Date __________________
MAIL ORIGINAL APPLICATION TO THE TAXPAYER SERVICE CENTER
LISTED ON THE REVERSE SIDE THAT SERVES THE COUNTY IN WHICH YOU ARE LOCATED.
REVENUE DEPARTMENT USE ONLY
examiner’s remarks ____________________________________________________________________________________________
_______________________________________________________________________________________________________________
examiner _____________________________________ Date ___________________
Supervisor’s recommendation ___________________________________________________________________________________
_______________________________________________________________________________________________________________
Supervisor _____________________________________ Date ___________________
ST: EX-A3
Reset
9/18
A
D
r
lAbAmA
epArtment of
evenue
S
u
t
D
AleS AnD
Se
Ax
iviSion
Application for State utility/mobile Communication
Services tax Certificate of exemption
Pursuant To Rule 810-6-5-.26.05
An Alabama utility/mobile Communication Services tax Certificate of exemption shall be used by persons, firms, or
corporations coming under the provisions of the utility Gross receipts tax and mobile Communication Services tax
statutes who are not required to have a utility tax and/or mobile communication services tax license.
PLEASE COMPLETE EACH LINE APPLICABLE TO YOUR BUSINESS. A UTILITY/MOBILE COMMUNICATION
SERVICES TAX CERTIFICATE OF EXEMPTION CANNOT BE ISSUED UNTIL THIS APPLICATION IS PROPERLY
COMPLETED.
1. federal employer identification number (fein) _______________________ 2. business telephone (_____)_____________
3. ____________________________________________________ _______________________________________________________
Legal name of person(s), firm, corporation, association, partnership making application.
Trade name
4. mailing address of home office _______________________________________________________________________________
P. O. Box or Street No. or R.F.D.
___________________________________________________________________________________________________________
City
County
State
Zip Code
5. number of businesses in Alabama __________ location__________________________________________________________
City
Street or Hwy. No.
County
location must be exact street number or, if on a highway or rural route, give details of the location. if more than one
location, please attach a schedule._____________________________________________________________________________
6. email (for renewal notification): ______________________________________________________________________________
7. Kind or class of business _____________________________________________________________________________________
wholesaler, reseller, broker, etc.
8. Kind of service(s) to be purchased tax-exempt:
electricity
Domestic Water
natural Gas
telegraph
telephone
mobile Communication
9. REASON(S) EXEMPTION CLAIMED ________________________________________________________________________
10. form of ownership:
individual  
partnership  
Corporation  
multi member llC  
Single member llC
if applicant is a corporation, a copy of the certified certificate of incorporation, amended certificate of incorporation, cer-
tificate of authority, or articles of incorporation should be attached. if the applicant is a limited liability company or a lim-
ited liability partnership, a copy of the certified articles of organization should be attached.
11. ownership information:
Corporations – give name, title, home address, and Social Security number of each officer.
partnerships/llp’s – give name, home address, Social Security number or fein of each partner, and valid Alabama
driver’s license or other acceptable citizenship documentation.
Sole proprietorships – give name, home address, Social Security number of owner, and valid Alabama driver’s license
or other acceptable citizenship documentation.
llC – give name, home address, and Social Security number or fein of each member. (valid Alabama driver’s license
or other acceptable citizenship documentation is required for single member llCs.)
llp – give name, title, home address, and Social Security number of each officer.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Signed _______________________________________________
Signed _______________________________________________
title __________________________ Date __________________
title __________________________ Date __________________
MAIL ORIGINAL APPLICATION TO THE TAXPAYER SERVICE CENTER
LISTED ON THE REVERSE SIDE THAT SERVES THE COUNTY IN WHICH YOU ARE LOCATED.
REVENUE DEPARTMENT USE ONLY
examiner’s remarks ____________________________________________________________________________________________
_______________________________________________________________________________________________________________
examiner _____________________________________ Date ___________________
Supervisor’s recommendation ___________________________________________________________________________________
_______________________________________________________________________________________________________________
Supervisor _____________________________________ Date ___________________
Taxpayer Service Centers
• AUBURN/OPELIkA
• MOBILE
3300 Skyway Drive, Auburn (Zip 36830)
bel Air tower Suite 100
3320 Skyway Drive, Suite 808
851 e. i-65 Service road South
opelika, Al 36801
mobile, Al 36606
telephone: (334) 887-9549
p.o. Drawer 160406
mobile, Al 36616-1406
Counties:
telephone: (251) 344-4737
Chambers
lee
talladega
Clay
randolph
tallapoosa
Counties:
Coosa
russell
baldwin
Conecuh
monroe
Choctaw
escambia
Washington
• DOTHAN
Clarke
mobile
Wilcox
121 Adris place (Zip 36303)
p.o. box 5739
• MONTGOMERY
Dothan, Al 36302-5739
2545 taylor road (Zip 36117)
telephone: (334) 793-5803
p.o. box 327490
montgomery, Al 36132-7490
Counties:
telephone (334) 242-2677
barbour
Dale
Henry
Coffee
Geneva
Houston
Counties:
Covington
Autauga
Crenshaw
macon
bullock
Dallas
montgomery
• GADSDEN
butler
elmore
pike
701 forrest Avenue (Zip 35901)
Chilton
lowndes
p.o. box 1190
Gadsden, Al 35902-1190
• TUSCALOOSA
telephone: (256) 547-0554
1434 22nd Avenue (Zip 35401)
p.o. box 2467
Counties:
tuscaloosa, Al 35403-2467
blount
Cleburne
marshall
telephone: (205) 759-2571
Calhoun
DeKalb
St. Clair
Cherokee
etowah
Counties:
bibb
marengo
Sumter
fayette
marion
tuscaloosa
• HUNTSVILLE
Greene
perry
Walker
4920 Corporate Drive, Suite H (Zip 35805)
Hale
pickens
Winston
p.o. box 11487
lamar
Huntsville, Al 35814-1487
telephone: (256) 837-2319
• OUT-OF-STATE:
Counties:
foreign Audit
Colbert
Jackson
limestone
Alabama Department of revenue
Cullman
lauderdale
madison
Sales and use tax Division
franklin
lawrence
morgan
p.o. box 327710
montgomery, Al 36132-7710
• JEFFERSON/SHELBY
2020 valleydale road, Suite 208 (Zip 35244)
• STATUTORILY EXEMPT ENTITIES:
p.o. box 1927
exemption unit
pelham, Al 35124
Alabama Department of revenue
telephone: (205) 733-2740
Sales and use tax Division
Counties:
p.o. box 327710
Jefferson
Shelby
montgomery, Al 36132-7710
Stexemptionunit@revenue.alabama.gov
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