Department of Taxation and Finance
New York State and Local Sales and Use Tax
Application for an Exempt Organization
Certicate - Information Authorization
ST-119.4
(7/17)
This Information Authorization is valid only for appointing a representative to receive oral or written communications in conjunction with
the review of your organization’s application for an Exempt Organization Certicate by the Sales Tax Exempt Organizations Unit. It may
not be used to protest the denial of an application for an Exempt Organization Certicate or to request a hearing before the Division
of Tax Appeals on such a denial since your appointed representative may not be a qualied representative for these purposes. Your
organization must use Form POA‑1, Power of Attorney, in these instances.
Organization Approved representative
Organization’s name
Mailing address (number and street or PO Box)
City and state
ZIP code
State the relationship of the appointed representative to your organization
Representative’s name
Mailing address
(number and street or PO Box)
City and state
ZIP code
Telephone number
( )
Email address
The organization named above appoints the person named above as its representative for the sole purpose of receiving all oral and
written communications and documents in connection with the organization’s application for exemption from sales and use taxes under
Tax Law section 1116(a).
By signing below, I certify, under penalty of perjury, that I am the ofcer, partner (except a limited partner), member or manager of a
limited liability company, or duciary acting on behalf of the organization listed above, and that I have the authority to execute this
Application for an Exempt Organization Certicate – Information Authorization.
Printed name Title Telephone number
( )
Signature Date
Type or print.
Ofcer or trustee
Mail your completed application to:
NYS TAX DEPARTMENT
SALES TAX EXEMPT ORGANIZATIONS SECTION
W A HARRIMAN CAMPUS
ALBANY, NY 12227-9154
If not using U.S. Mail, see Publication 55, Designated Private Delivery Services.
