Free DR-700025 - Florida

Objection to Address/Jurisdiction Database for Local Communications Services Tax and Local Insurance Premium Tax Service Address Assignment
Part A: Contact Information
I am a (check one): Communications services dealer Insurance Company Purchaser of communications services Insured

Mail to: Local Government Unit Florida Department of Revenue PO Box 6530 Tallahassee FL 32314-6530

DR-700025 R. 10/06

DOR CST or IPT Vendor

Name of person objecting to address assignment ____________________________________________________________________ Title (if applicable) ______________________________________ City/State/ZIP __________________________________________ Telephone number ______________________________________ Address ______________________________________________ E-mail address ________________________________________ 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 ________________________________________ County ______________________________________________ City _________________________________________________ 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 number ___________________________________ City ________________________________ Address Range AUX Key number _______________________ and Street ___________________________________________ ZIP _____________________________

County_______________________________

Address Range is contained in database with effective date of _________________________________________________________

Part C: Basis for Objection Reason 1.

Complete the appropriate reason based on your objection (check only one box).

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. Reason 3:

The address or range is not listed in the address/jurisdiction database.
Proposed jurisdiction where address or range should be assigned _______________________________________

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 _______________________________

DR-700025 R. 10/06 Page 2

Instructions for Completing Form DR-700025
Who may use this form? This form may be used by a communications services dealer, purchaser of communications or insurance services, Communications Services Tax (CST) Vendor, Insurance Premium Tax (IPT) vendor or other substantially affected party to object to information contained in the Department of Revenue's address/jurisdiction database. This form may not be used by local taxing jurisdictions to make corrections or updates to the address/jurisdiction database. Local taxing jurisdictions should use Form DR-700022, Notification of Jurisdiction Change for Local Communications Services and Local Insurance Premium Tax. Special Fire Districts should use Form DR-350907. Firefighters and police officers, including pension board members, with concerns about the Local Insurance Premium Tax and the address/jurisdiction database should communicate with the appropriate official within their local jurisdiction, either the city or special fire district, regarding database address changes. Step 1. Complete Part A: Contact Information Step 2. Complete Part B: Address Information If you are a communications services dealer, insurance company, CST or IPT vendor you are encouraged to use the address range associated with the service address you are objecting to. You may submit multiple addresses or ranges in this section but if so you are encouraged to submit them electronically. Also see Step 3 regarding multiple addresses or ranges. Be sure to use the most current version of the database for address information. Step 3. Complete Part C: Basis for Objection Check the box for the reason that applies to your objection. You should check only one box per form. If you are a communications services dealer, insurance company, CST or IPT vendor and are submitting multiple addresses or ranges affecting multiple jurisdictions, each combination should be segregated based on the specific combination of the affected jurisdictions and basis for objections. You should use a separate form for each combination. (EX: Addresses or ranges moving from City A to City B should be on one form. Addresses or ranges moving from City A to City C should be on a separate form.) You are encouraged to submit the segregated information electronically by CD or diskette. Step 4. Complete Part D: Competent Evidence Competent evidence must be attached to this form. Briefly describe the evidence you have attached in the space provided. Examples of competent evidence include: · A voter registration card that indicates the voter resides at a service address that is entitled to vote in municipal elections or only in county elections. · A map that includes the boundaries of a local taxing jurisdiction and clearly places a service address inside or outside those boundaries. · Property tax bill. Communications services dealers in possession of MSAG/911 data may attach a written statement indicating that the data was consulted. Step 5. Complete Part E: Sign and date the form. Mail to: Florida Department of Revenue Local Government Unit PO Box 6530 Tallahassee, FL 32314-6530 For overnight or other delivery requiring a street address, use: Florida Department of Revenue Local Government Unit 5050 W. Tennessee St. Bldg E-1 Tallahassee, FL 32304-9201 Or Fax to: 850-921-4711 For communications services dealers, insurance companies, CST or IPT vendors, send address diskettes to the above address. Upon receipt of this form, the Department will contact the local jurisdiction(s) pursuant to departmental rules. For more information, call the Department's Local Government Unit at 850-921-9181 or e-mail to: [email protected] Persons with hearing or speech impairments may call the TDD line at 800-367-8331 or 850-922-1115.