TENNESSEE CONSUMERS TAX REFUND FORM

REQUEST FOR REFUND* OF SALES TAX PAID ON INTERNET ACCESS SERVICES PROVIDED BY
HEART OF TENNESSEE NETWORK, LLC.

*Note All line items on this Request for Refund Form must be 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
considered.

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 Network at 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 that 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 Network
3235 Windsor Green Drive
Murfreesboro, TN     37129

ONLY completed, signed Request for Refund forms received at 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 than U.S. mail at the address indicated above will not be
considered eligible for consideration for refund.

 

http://www.heartoftn.net/InternetSalesTax.html