DR-700025
Objection to Address/Jurisdiction Database for Local
R. 10/13
Communications Services Tax and Local Insurance
Rule 12A-19.100
Florida Administrative Code
Premium Tax Service Address Assignment
All requests can be submitted using the Department of Revenue’s Internet site at: https://pointmatch.state.fl.us
Part A: Contact Information
I am a (check one):
❏ Communications Services Provider
❏ Individual (insured or purchaser of communications services)
❏ FDOR Employee
❏ Insurance Company or Vendor
❏ Communications Services Tax Address Vendor
Name:_____________________________________________
Title: ______________________________________________________
Company: _________________________________________
Street Address: _____________________________________________
City/State/ZIP: _____________________________________
E-mail address: _____________________________________________
Phone Number: ____________________________________
Fax Number: _______________________________________________
Part B: Service Address Information
To submit an objection for multiple addresses, use the Department's Internet site at:
https://pointmatch.state.fl.us or contact us at 850-717-6630 for more information.
Required for all requests.
The service address I am objecting to has an effective date (if known) of: ________________________________________________
Number and Street________________________________________
City: ________________________________________________
County: _________________________________________________
ZIP: _________________________________________________
For FDOR Employees only. For SUNTAX related requests, provide all of the following:
Business Partner #: _______________________________________
Certificate #: _________________________________________
Tax Type: ________________________________________________
Owner Name (if not sole proprietor): ____________________
Account Name: __________________________________________
Owner Phone: _______________________________________
Part C: Basis for Objection
Complete the appropriate reason based on your objection (check all that apply).
Reason 1.
❏
The address is listed in the wrong jurisdiction within the database. Current jurisdictional assignment is
______________________________________________. Proposed jurisdiction assignment should be
______________________________________________.
Reason 2.
The address is not listed in the database. Proposed jurisdiction assignment should be
❏
______________________________________________.
Reason 3:
The address information is incorrect (EX. misspelled, wrong ZIP code). Proposed correction to address: _____
❏
__________________________________________________________________________________________________
__________________________________________________________________________________________________
If none of these reasons apply, use the space below to describe your objection:
Reason 4:
__________________________________________________________________________________________________
❏
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________