Form 72-15-09 "Affidavit for Church Utility Exemption" - Mississippi

What Is Form 72-15-09?

This is a legal form that was released by the Mississippi Department of Revenue - a government authority operating within Mississippi. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Mississippi Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 72-15-09 by clicking the link below or browse more documents and templates provided by the Mississippi Department of Revenue.

ADVERTISEMENT
ADVERTISEMENT

Download Form 72-15-09 "Affidavit for Church Utility Exemption" - Mississippi

542 times
Rate (4.4 / 5) 38 votes
AFFIDAVIT FOR
CHURCH UTILITY EXEMPTION
Form 72-15-09
S
O
M
TATE
F
ISSISSIPPI
, COUNTY OF ___________________________________________________ BEFORE ME, the
undersigned authority, on this day personally appeared __________________________________________________, who after being
(NAME)
by me first duly sworn, on oath deposed and said:
Under the penalty of perjury,
I hereby certify that the church, ____________________________________________________________________________, is
exempt from federal income taxation under 26 USCS Section 501(c)3. I hereby certify that I am authorized to represent the church
named above in legal matters. I further certify that potable water, electricity, current, power, natural gas, liquefied petroleum gas
or other fuel purchased by the church named above will be utilized on property that is primarily used for religious or educational
purposes and qualifies for exemption from sales tax as provided in Miss. Code Ann. Section 27-65-19.
I understand that utilities at facilities used for commercial business activities such as thrift stores, etc. do not qualify for exemption
from sales tax. I further certify and agree that if the above named church does not meet the requirements for exemption from
federal income taxation under 26 USCS Section 501(c)3 or if the Internal Revenue Service revokes the 26 USCS Section 501(c)3
status of the above named church, the church 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 from the date of purchase on
all taxable utilities purchased by the church.
I affirm that if the above named church ceases to meet the requirements for exemption from federal income taxation under 26
USCS Section 501(c)3 or if the Internal Revenue Service revokes the 26 USCS Section 501(c)3 status of the church prior to
December 31, of the current year, the church will notify the utility companies so that applicable sales tax rates may be charged on
future purchases.
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 CHURCH)
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 FOR
CHURCH UTILITY EXEMPTION
Form 72-15-09
S
O
M
TATE
F
ISSISSIPPI
, COUNTY OF ___________________________________________________ BEFORE ME, the
undersigned authority, on this day personally appeared __________________________________________________, who after being
(NAME)
by me first duly sworn, on oath deposed and said:
Under the penalty of perjury,
I hereby certify that the church, ____________________________________________________________________________, is
exempt from federal income taxation under 26 USCS Section 501(c)3. I hereby certify that I am authorized to represent the church
named above in legal matters. I further certify that potable water, electricity, current, power, natural gas, liquefied petroleum gas
or other fuel purchased by the church named above will be utilized on property that is primarily used for religious or educational
purposes and qualifies for exemption from sales tax as provided in Miss. Code Ann. Section 27-65-19.
I understand that utilities at facilities used for commercial business activities such as thrift stores, etc. do not qualify for exemption
from sales tax. I further certify and agree that if the above named church does not meet the requirements for exemption from
federal income taxation under 26 USCS Section 501(c)3 or if the Internal Revenue Service revokes the 26 USCS Section 501(c)3
status of the above named church, the church 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 from the date of purchase on
all taxable utilities purchased by the church.
I affirm that if the above named church ceases to meet the requirements for exemption from federal income taxation under 26
USCS Section 501(c)3 or if the Internal Revenue Service revokes the 26 USCS Section 501(c)3 status of the church prior to
December 31, of the current year, the church will notify the utility companies so that applicable sales tax rates may be charged on
future purchases.
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 CHURCH)
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