Form 5506cpe-0505 - Application For Exemption From Public Utility Tax Upon Cell Phones - 2014

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STATE OF DELAWARE
2014 APPLICATION FOR
EXEMPTION FROM PUBLIC UTILITY
Division of Revenue
Print Form
TAX UPON CELL PHONES
Business Audit Bureau
820 N. French Street
FORM 5506CPE-0505
Wilmington, Delaware 19801
EXEMPTION PERIOD:
TO 12/31/2014
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 Street Address:
City:
State:
Zip Code:
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:
Owner/Lessee
Other (Please explain)
(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
*DF40714019999*
(Revised 12/04/13)

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