“THE SKY CITY” by pengxiuhui


									P.O. Box 309                                              “THE SKY CITY”                                  Telephone: (505) 552-5125/5126
Pueblo of Acoma, NM 87034                        Office of Taxation and Assessments                             Facsimile: (505) 552-7204

                                              NATIVE AMERICAN EXEMPTION FORM

Vendor Name: ___________________

Customer Name (as it appears on the billing statement): ______________________ Cellular Number: ____________________

Contact Number: ____________________ Account Number: (for Alltel customers only) _______________________________

Exemption from Certain Taxes and Surcharges
         You may be exempt from various taxes and surcharges that are applied to your communications bill if you are: (1) a
governmental entity of the Pueblo or Tribe; (2) a member of the Pueblo or Tribe residing on your Pueblo or Reservation; or (3) a
business owned by the Pueblo or Tribe and located on and doing business on the Pueblo or Reservation.

The taxes and surcharges from which you may be exempt are:
        1.       State, City and County Gross Receipts [Sales] Taxes*;
        2.       911 surcharge fees;
        3.       Municipal/County franchise fees;
        4.       Telecommunications Relay Service Surcharge;
        5.       New Mexico Universal Service Charge.
        6.       Other __________________________

*The exemption does not apply to any taxes being imposed directly by the Tribe or Pueblo and collected by the above referenced

           The undersigned certifies that as an individual, or the entity they own or represent, they are entitled to an exemption from
state taxes for purchases of communication services by Native Americans that are delivered through an instrument located on tribal
⇒ The Customer is (check one): ( ) Tribal Government Agency ( ) An Enrolled Tribal Member ( ) Business wholly owned by the
Tribe or Member.

⇒ The undersigned is a member of the ______________________________; ___________________________
                                               (Name of Tribe)                     (BIA or Tribal Census Number)

Tribal Member Signature

If the Tribal Member does not have or does not want to divulge his/her official BIA or tribal census number or the entity being
exempted is a tribal government agency, the following attestation must by signed by an official of the purchaser’s tribe.**

I, _______________ hold the position of ____________________, as an official of the tribe of ______________, do hereby certify
that the above named individual is a member of such tribe, reside on their reservation or that the customer is an Indian tribal agency.

(Officials Signature)                                   (Date)

**Signature is not required if Tribal Official is attesting for a tribal member.

Return completed exemption form via mail, fax or email address to:.

Mailing Address:     Verizon Wireless                                 Fax: Attn: Mary Beth 1-800-734-4707
                     Attn: Tax Exempt Group
                     1120 Sanctuary Parkway Ste. 150
                     Alpharetta, Georgia 30009-7630

Email:               sogaatlhq_taxexemptgroup@se.verizonwireless.com


Exemption forms may only be faxed to (501) 905-6828.


Sprint does not accept the Native American Exemption Form and customers will need to contact the Finance Department at Sprint at
866-866-7509 and have a Sprint Tax exemption form mailed. Upon receipt, the tax exemption form may only be faxed to 866-703-
7240 (Sprint is only able to provide this form to customers who call in to request one.)

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