Form Rt-12 - Request For Determination Of Proper Tax Jurisdiction
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Illinois Department of Revenue
RT-12
Request for Determination of Proper Tax Jurisdiction
Step 1: Read this first
If you believe you are improperly being charged the Simplified Municipal Telecommunication Tax because your service address is
assigned to the wrong taxing jurisdiction, you must first file a written complaint with your telecommunications service provider. If you
disagree with your service provider’s response to your written complaint, complete Form RT-12 to request determination of proper tax
jurisdiction by the Illinois Department of Revenue.
Step 2: Identify yourself
Name: _______________________________________________
Telephone number: (___ ___ ___) ___ ___ ___-___ ___ ___ ___
(as it appears on your telecommunications billing statement)
Address: ___________________________________________________________________________________________________
(
as it appears on your telecommunications billing statement)
City
State
ZIP
Your telecommunication account number
(if different from your telephone number listed above): ___________________________________
Step 3: Identify where your telecommunications service is provided
Address: _____________________________________________
County: _____________________________________________
City, state, ZIP: ______________________________________________________________________________________________
Step 4: Identify your telecommunications service provider
Name: _______________________________________________
Telephone number: (___ ___ ___) ___ ___ ___-___ ___ ___ ___
Address: ___________________________________________________________________________________________________
Number and street
City
State
ZIP
Step 5: Provide information from your written complaint
1 Did you file a written complaint with your telecommunications service provider? ____yes
____no
If you checked “no,” you must first file a written complaint with your telecommunications service provider. If, after you receive a
•
response from the telecommunications service provider, you disagree with the response, you may then file Form RT-12.
If you checked “yes,” and you disagree with the telecommunications service provider’s response, complete the following
•
information regarding your complaint.
2 Date you submitted your written complaint to your service provider: __ __/__ __/__ __ __ __
3 Date you received a response to your written complaint: __ __/__ __/__ __ __ __
4 Estimated tax you overpaid: $___________________.
5 Beginning month and year for which the overpayment applies: __ __/__ __ __ __
6 Taxing jurisdiction assigned to you by your telecommunications service provider:______________________________________
7 Any other information you included in your complaint to your telecommunications service provider:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Mail to:
LOCAL TAX ALLOCATION DIVISION
ILLINOIS DEPARTMENT OF REVENUE
*091701110*
101 WEST JEFFERSON MC 3-500
SPRINGFIELD IL 62702
RT-12 (R-04/10)
This form is authorized as outlined by the Simplified Municipal Telecommunications Tax Act. Disclosure of this
information is REQUIRED. This form has been approved by the Forms Management Center. IL-492-4315
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