Exemption of CERTIFICATE
(Date) __________________________ 19____
I certify that ______________________
(Name of service)
have been furnished by _______________________________
(Telephone, telegraph company, etc.)
to ____________________ (International Organization, etc.); that the charges of $______ will be paid from ____________________ (International Organization, etc.) funds; and that the charges are exempt from tax under section 4253(c) of the Internal Revenue Code.
_______________________________
(Signature of officer or employee)
_______________________________
(Address)
_______________________________
(Title)
26 C.F.R. §49.4253-3
Penalty for fraudulent use, $10,000 or imprisonment or both.