TENNESSEE CONSUMERS TAX REFUND FORM
REQUEST FOR REFUND* OF SALES TAX PAID
INTERNET ACCESS SERVICES PROVIDED BY
HEART OF TENNESSEE NETWORK, LLC.
*Note All line items on this Request for Refund Form
fully completed in order for request to be considered eligible
for consideration of a refund. Partially completed Request for Refund Forms, including those without a signature, will not be
Full Name: _________________________________________________________________
Account Name (Same as your Primary Email Address): _________________________________________
Mailing Address (Including City, State and Zip code): ___________________________________________________
(If you have been a customer of Heart Of Tennessee
another address in Tennessee since December 1, 2000,
please list these earlier addresses below and the period of residence.)
Period of Residence at earlier mailing address: _____________________________________________________________
Area Code and Phone Number at Mailing Address: ______________________________________________
By signing below, I certify to the best of my ability
all of the information I have provided in this Request for
Refund, is correct and accurate.
Signature (must be the name on the account listed above) Date
The Request for Refund Form must be mailed to:
Heart Of Tennessee
3235 Windsor Green Drive
Murfreesboro, TN 37129
ONLY completed, signed Request for Refund forms
the address included above and postmarked by
July 17, 2004 will be considered for refund. Heart Of Tennessee Network, LLC is not responsible for any
Request for Refund forms lost in the mail or otherwise not received at the address posted above by July 17, 2004.
Request for Refund forms received in any manner other
U.S. mail at the address indicated above will not be
considered eligible for consideration for refund.