Form 5506cpe-0505 - Application For Exemption From Public Utility Tax Upon Cell Phones - 2011

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2011 APPLICATION FOR
Reset
STATE OF DELAWARE
EXEMPTION FROM PUBLIC UTILITY
Print Form
TAX UPON CELL PHONES
Division of Revenue
Business Audit Bureau
FORM 5506CPE-0505
820 N. French Street
Wilmington, Delaware 19801
EXEMPTION PERIOD: __/__/__ TO 12/31/2011
THIS APPLICATION APPLIES TO OWNERS OF CELL PHONES WITHIN THE STATE OF DELAWARE.
THIS APPLICATION MUST BE COMPLETED AND FILED ANNUALLY WITH THE DELAWARE DIVISION OF REVENUE
TO QUALIFY FOR EXEMPTION FROM THE DELAWARE PUBLIC UTILITY TAX THAT IS ASSESSED
UPON OWNERS OF CELL PHONES WITH A DELAWARE BILLING ADDRESS.
1.
Social Security Number
2.
Name
3.
Resident Address
4.
Cell Phone Number
5.
Cell Phone Provider
6.
Please check one of the following in regards to your resident address listed on Line 3 of this application:
[
]
O
w
n
r e
L /
e
s s
e
e
[
]
O
h t
r e
P (
e l
a
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e
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p
a l
n i
_ )
_
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(You must furnish a copy of your cell phone bill and driver’s license, or another document with your name and address,
such as a personal id, utility bill, property tax bill or lease agreement.)
7.
Is the residence equipped with an operating Internet connection?
[ ] Yes (Proceed to Question 8)
[ ] No (Proceed to Question 9)
8.
Please check the type of operating Internet connection installed in the residence:
[ ] Landline Telephone
[ ] High-Speed DSL
[ ] High-Speed Cable
9.
Is the residence equipped with an operating fax connection?
[ ] Yes (Proceed to Question 10)
[ ] No
10.
Please check the type of fax connection installed in the residence:
[ ] Landline Telephone
[ ] High-Speed DSL
[ ] High-Speed Cable
I declare under penalties as provided by law that there is no other telephone service at the resident address provided
on this application and the information on this application is true, correct and complete.
Sign and return form to above address.
Applicant Signature
Date
FOR DIVISION OF REVENUE USE
APPROVED [ ]
DISAPPROVED [ ]
Explanation
Official Signature
Name (Please Print)
Title
Date
(Revised 12/08/10)

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