Please Provide:
• A copy of your federal 501(c)(3) leer
• Documentaon that you meet one of the following requirements:
This facility is cered to parcipate in the medical assistance program under Title 19 of the Social Security Act.
This facility does not discharge residents due to the inability to pay. Include a copy of the facility’s discharge policy.
This facility is exempt from property tax. Include a copy of the facility’s most current property tax statement.
Organizaon Name Phone
Mailing Address City State ZIP Code
Main Business Address in Minnesota (If Dierent From Above) City State ZIP Code
Federal Tax ID Number Minnesota Tax ID Number Phone Email Address
Form ST16A, Applicaon for Nonprot Exempt Status—Sales Tax
Nursing Homes and Boarding Care Homes
Sign Here
I declare this form and supporng documentaon is correct and complete to the best of my knowledge and belief and I am authorized to sign on
behalf of the organizaon.
Signature Title Date Phone
Preparer Signature Preparer Minnesota Tax ID Number Date Preparer Phone
Send Form ST16A, supporng documents, and Form REV184, Power of Aorney (if applicable), to:
Mail:
Email:
Minnesota Department of Revenue
Mail Staon 6330
600 N. Robert St.
St. Paul, MN 55146-6330
Nonprot.exemptstatus@state.mn.us
The Applicaon Process
• We will link your applicaon to your Minnesota Tax ID Number to track the status of your applicaon. If your organizaon does not have a
Minnesota Tax ID Number, we will assign one to you.
• Allow up to 60 days to receive a determinaon on your applicaon.
• We may request addional informaon to determine if your organizaon qualies for exempt status.
Rev. 9/19
