Form Dr-700022 - Notification Of Jurisdiction Change For Local Communications Services And Local Insurance Premium Tax
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1
2DR-700022
Notification of Jurisdiction Change for
R. 10/13
Local Communications Services and Local Insurance Premium Tax
Rule 12A-19.100
Florida Administrative Code
Effective 01/14
All jurisdiction change requests must be submitted using the Department of Revenue’s Internet site at
https://pointmatch.state.fl.us.
Name of jurisdiction initiating change
County
Effective date of change (check only one)
❏
❏
January 1, _______
July 1, _______
NOTE:
Case number
The case number is assigned by the Department’s address database once change
records are submitted. The database is available at https://pointmatch.state.fl.us
✓
Type of jurisdiction change (
check one)
❏
❏
❏
❏
Street address correction
New address
Annexation
Incorporation
❏
❏
❏
Disincorporation
Reorganization
Other _______________________
❏
❏
Does this change affect another local jurisdiction?
Yes
No
If yes, enter affected jurisdiction ___________________________________
OFFICIAL AUTHORIZATION
Part A
Part B
Initiating jurisdiction
Affected jurisdiction
Name of authorizing official
Name of authorizing official (See Instructions - Step 4.)
Title
Title
Telephone
Fax
Telephone
Fax
E-mail
E-mail
I have reviewed the proposed jurisdiction changes for accuracy. I am an authorized
I have reviewed the proposed jurisdiction changes for accuracy. I am an authorized
representative of the Florida jurisdiction requesting these changes. I authorize the
representative of the Florida jurisdiction affected by these changes. I authorize the
Department of Revenue to modify the address/jurisdiction database to reflect these
Department of Revenue to modify the address/jurisdiction database to reflect these
changes.
changes.
Signature ________________________________________________________
Signature ________________________________________________________
Date _____________________________________________________________
Date _____________________________________________________________
Part C. Complete this part only if you are unable to obtain the written consent of the affected jurisdiction.
Affected jurisdiction
Name of authorizing official contacted
✓
Method of contact (
check all that apply)
❏
Telephone
❏
Mail
❏
E-mail
❏
Fax
❏
Other
I have contacted the authorizing official named above and have been unable to obtain a signature in Part B.
Signature of authorized representative of initiating jurisdiction _____________________________________________________________________________
FOR DOR USE ONLY
Date Received ___________________________
Worked By ______________________________
Action _________________________________
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