Form 72-621-13 "Affidavit of a School or Affiliated Organization Purchasing Fundraising Materials" - Mississippi

Form 72-621-13 or the "Affidavit Of A School Or Affiliated Organization Purchasing Fundraising Materials" is a form issued by the Mississippi Department of Revenue.

Download a PDF version of the latest Form 72-621-13 down below or find it on the Mississippi Department of Revenue Forms website.

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Download Form 72-621-13 "Affidavit of a School or Affiliated Organization Purchasing Fundraising Materials" - Mississippi

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AFFIDAVIT OF A SCHOOL OR
AFFILIATED ORGANIZATION
PURCHASING FUNDRAISING MATERIALS
Form 72-621-13
S
O
M
TATE
F
ISSISSIPPI
, COUNTY OF ___________________________________________________ BEFORE ME, the
undersigned authority, on this day personally appeared __________________________________________________________, of
(NAME)
________________________________________________________________, who after being by me first duly sworn, on oath
(SCHOOL OR AFFILIATED ORGANZIATION)
deposed and said:
Under the penalty of perjury,
I hereby certify that the organization named above is a school or an organization affiliated with a school. I hereby certify that I
am authorized to represent the organization named above in business matters and that all exempt purchases of tangible personal
property by the school or affiliated organization will be used for the sole purpose of raising funds for that school or affiliated
organization.
I understand that a school is defined under Miss. Code Ann. § 27-65-111(cc) as any public or private school that teaches courses
of instruction to students in any grade from Kindergarten through Grade 12. I understand that a school does not include a private
school where the courses of study are limited to specialized subjects such as dance, cooking, music or sewing.
I further certify and agree that if the above named school or affiliated organization does not meet the requirements for exemption
under Miss. Code Ann. § 27-65-111(cc) for purchases of tangible personal property that the school or affiliated organization will
pay to the Mississippi Department of Revenue the full seven percent (7%) retail sales tax rate, plus a fifty percent (50%) fraud
penalty and the applicable rate of interest per month provided in Miss. Code Ann. § 27-65-39.
I affirm that if the above named school or affiliated organization ceases to meet the requirements for exemption under Miss.
Code Ann. § 27-65-111(cc), prior to December 31, of the current year, the school or affiliated organization will notify the
vendors that were presented copies of this affidavit so that applicable sales tax rates may be charged on future purchases.
THIS AFFIDAVIT WILL ONLY SUPPORT THE EXEMPTION OF SALES TAX ON TANGIBLE PERSONAL PROPERTY
SOLD TO THE SCHOOL OR AFFILIATED ORGANIZATION THROUGH DECEMBER 31, _________. I understand
purchases made after December 31, of the current year will require a new affidavit.
WITNESS MY SIGNATURE, this the ______ day of _________________, 20____.
________________________________________________
_______________________________________________
(PRINTED NAME)
(SIGNATURE)
___________________________________________________________________________________________________
(STREET ADDRESS)
___________________________________________________________________________________________________
(MAILING ADDRESS)
Telephone Numbers: Work – (___) _______________ Home - (___) _________________
______________________________________________________________________________________________________________________________
NOTARY PUBLIC ACKNOWLEDGEMENT
STATE OF MISSISSIPPI, COUNTY OF ________________________
Personally came and appeared before me, the undersigned authority in and for the said county and state, on this ________ day of
__________________, 20____, within my jurisdiction, the within named _______________________________, who acknowledged
that he/she is the ___________________________ of __________________________________________________ and that in said
(TITLE)
(NAME OF SCHOOL OR AFFILIATED ORGANIZATION)
representative capacity he/she executed the above and foregoing instrument after having been duly authorized so to do.
Printed Name: _____________________________________
[Place Seal Here]
Signature: _____________________________________
My Commission Expires: _____________________________________
P.O. Box 1033,
Jackson, MS 39215
www.dor.ms.gov
Phone: 601.923.7015
FAX: 601.923.7034
AFFIDAVIT OF A SCHOOL OR
AFFILIATED ORGANIZATION
PURCHASING FUNDRAISING MATERIALS
Form 72-621-13
S
O
M
TATE
F
ISSISSIPPI
, COUNTY OF ___________________________________________________ BEFORE ME, the
undersigned authority, on this day personally appeared __________________________________________________________, of
(NAME)
________________________________________________________________, who after being by me first duly sworn, on oath
(SCHOOL OR AFFILIATED ORGANZIATION)
deposed and said:
Under the penalty of perjury,
I hereby certify that the organization named above is a school or an organization affiliated with a school. I hereby certify that I
am authorized to represent the organization named above in business matters and that all exempt purchases of tangible personal
property by the school or affiliated organization will be used for the sole purpose of raising funds for that school or affiliated
organization.
I understand that a school is defined under Miss. Code Ann. § 27-65-111(cc) as any public or private school that teaches courses
of instruction to students in any grade from Kindergarten through Grade 12. I understand that a school does not include a private
school where the courses of study are limited to specialized subjects such as dance, cooking, music or sewing.
I further certify and agree that if the above named school or affiliated organization does not meet the requirements for exemption
under Miss. Code Ann. § 27-65-111(cc) for purchases of tangible personal property that the school or affiliated organization will
pay to the Mississippi Department of Revenue the full seven percent (7%) retail sales tax rate, plus a fifty percent (50%) fraud
penalty and the applicable rate of interest per month provided in Miss. Code Ann. § 27-65-39.
I affirm that if the above named school or affiliated organization ceases to meet the requirements for exemption under Miss.
Code Ann. § 27-65-111(cc), prior to December 31, of the current year, the school or affiliated organization will notify the
vendors that were presented copies of this affidavit so that applicable sales tax rates may be charged on future purchases.
THIS AFFIDAVIT WILL ONLY SUPPORT THE EXEMPTION OF SALES TAX ON TANGIBLE PERSONAL PROPERTY
SOLD TO THE SCHOOL OR AFFILIATED ORGANIZATION THROUGH DECEMBER 31, _________. I understand
purchases made after December 31, of the current year will require a new affidavit.
WITNESS MY SIGNATURE, this the ______ day of _________________, 20____.
________________________________________________
_______________________________________________
(PRINTED NAME)
(SIGNATURE)
___________________________________________________________________________________________________
(STREET ADDRESS)
___________________________________________________________________________________________________
(MAILING ADDRESS)
Telephone Numbers: Work – (___) _______________ Home - (___) _________________
______________________________________________________________________________________________________________________________
NOTARY PUBLIC ACKNOWLEDGEMENT
STATE OF MISSISSIPPI, COUNTY OF ________________________
Personally came and appeared before me, the undersigned authority in and for the said county and state, on this ________ day of
__________________, 20____, within my jurisdiction, the within named _______________________________, who acknowledged
that he/she is the ___________________________ of __________________________________________________ and that in said
(TITLE)
(NAME OF SCHOOL OR AFFILIATED ORGANIZATION)
representative capacity he/she executed the above and foregoing instrument after having been duly authorized so to do.
Printed Name: _____________________________________
[Place Seal Here]
Signature: _____________________________________
My Commission Expires: _____________________________________
P.O. Box 1033,
Jackson, MS 39215
www.dor.ms.gov
Phone: 601.923.7015
FAX: 601.923.7034
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