Form Dr-700025 - Objection To Address/jurisdiction Database For Local Communications Services Tax And Local Insurance Premium Tax Service Address Assignment
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1
2DR-700025
Objection to Address/Jurisdiction Database for
R. 10/06
Local Communications Services Tax and
Mail to:
TC
Local Government Unit
Local Insurance Premium Tax
Florida Department of Revenue
Service Address Assignment
PO Box 6530
Tallahassee FL 32314-6530
Part A: Contact Information
I am a (✓check one):
❏ Communications services dealer
❏ Purchaser of communications services
❏ DOR
❏ Insurance Company
❏ Insured
❏ CST or IPT Vendor
Name of person objecting to address assignment ____________________________________________________________________
Title (if applicable) ______________________________________
Address ______________________________________________
City/State/ZIP __________________________________________
E-mail address ________________________________________
Telephone number ______________________________________
Fax number ___________________________________________
Part B: Address Information
❏ For completion by an individual Purchaser of Communications or Insurance Services.
The service address I am objecting to:
Number and street ________________________________________
City _________________________________________________
County
______________________________________________
ZIP _________________________________________________
❏ For completion by a Communications Services Dealer, Insurance Company, CST or IPT Vendor or DOR.
NOTE: See instructions for electronic submission and multiple range submissions.
The address range as listed in the database I am objecting to:
Address Range Update Key number ("Y" key) ________________
Address Range AUX Key number _______________________
Address Range number ___________________________________
and Street ___________________________________________
City ________________________________
County_______________________________
ZIP _____________________________
Address Range is contained in database with effective date of _________________________________________________________
Part C: Basis for Objection
Complete the appropriate reason based on your objection (check only one box).
Reason 1.
The address or range is listed in the wrong jurisdiction within the address/jurisdiction database.
❏
Jurisdiction where address or range is now assigned __________________________________________________
Proposed jurisdiction where address or range should be assigned _______________________________________
Reason 2.
❏
The address or range is not listed in the address/jurisdiction database.
Proposed jurisdiction where address or range should be assigned _______________________________________
Reason 3:
The information about the address or range is incorrect.
❏
Proposed correction to information __________________________________________________________________
Jurisdiction where address or range is now assigned ___________________________________________________
Part D: Competent Evidence
I have attached the following competent evidence to support my objections,
(describe evidence) _________________________________________________________________________________________________
Part E: Signature/Date
Signature ___________________________________________________________________
Date _______________________________
FOR DOR USE ONLY
Tracking number ____________________________________________________________
Date _______________________________
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