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pdfOMB Approval No. 1405-0105
Expires: xx-xx-xxxx
Estimated burden: 5 minutes*
U.S. Department of State
(PLEASE TYPE)
PID NUMBER
APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON UTILITIES
TYPE OF
ACCOUNT
Personal
LOCATION (City)
COUNTRY
Mission
NAME - OFFICE OR INDIVIDUAL (Last, First, MI) (For Office, please also include a contact person)
STREET ADDRESS
CITY
COUNTY
ZIP CODE
STATE
USE OF PREMISES
Residential
TELEPHONE
Official
GAS
ELECTRIC
WATER
ACCOUNT NUMBER
UTILITY COMPANY NAME
SIGNATURE & TITLE OF APPLICANT OR AUTHORIZED OFFICER
OTHER
METER NUMBER
TELEPHONE NUMBER
DATE (mm-dd-yyyy)
AREA CODE (
)
FOR OFFICE USE ONLY
EMBASSY
CONSULATE
UN
OAS
OTHER
DS-98 (Formerly DSP-99)
xx-xxxx
Page 1 of 2
OMB Approval No. 1405-0105
Expires: xx-xx-xxxx
Estimated burden: 5 minutes*
U.S. Department of State
(PLEASE TYPE)
PID NUMBER
APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON UTILITIES
TYPE OF
ACCOUNT
Personal
LOCATION (City)
COUNTRY
Mission
NAME - OFFICE OR INDIVIDUAL (Last, First, MI) (For Office, please also include a contact person)
STREET ADDRESS
CITY
COUNTY
ZIP CODE
STATE
USE OF PREMISES
Residential
TELEPHONE
Official
GAS
ELECTRIC
WATER
ACCOUNT NUMBER
UTILITY COMPANY NAME
SIGNATURE & TITLE OF APPLICANT OR AUTHORIZED OFFICER
OTHER
METER NUMBER
TELEPHONE NUMBER
DATE (mm-dd-yyyy)
AREA CODE (
)
FOR OFFICE USE ONLY
EMBASSY
CONSULATE
UN
OAS
OTHER
DS-98 (Formerly DSP-99)
xx-xxxx
Page 1 of 2
OMB Approval No. 1405-0105
Expires: xx-xx-xxxx
Estimated burden: 5 minutes*
U.S. Department of State
(PLEASE TYPE)
PID NUMBER
APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON UTILITIES
TYPE OF
ACCOUNT
Personal
LOCATION (City)
COUNTRY
Mission
NAME - OFFICE OR INDIVIDUAL (Last, First, MI) (For Office, please also include a contact person)
STREET ADDRESS
CITY
COUNTY
ZIP CODE
STATE
USE OF PREMISES
Residential
TELEPHONE
Official
GAS
ELECTRIC
ACCOUNT NUMBER
UTILITY COMPANY NAME
SIGNATURE & TITLE OF APPLICANT OR AUTHORIZED OFFICER
DATE (mm-dd-yyyy)
WATER
OTHER
METER NUMBER
TELEPHONE NUMBER
AREA CODE (
)
FOR OFFICE USE ONLY
EMBASSY
DS-98 (Formerly DSP-99)
xx-xxxx
CONSULATE
UN
OAS
OTHER
Page 1 of 2
Privacy Act Statement
AUTHORITIES: The information is sought pursuant to Vienna Convention on Diplomatic Relations of 1961; Vienna Convention on Consular
Relations of 1963; Diplomatic Relations Act (22 U.S.C. 254a-e); International Organizations Immunities Act (22 U.S.C. 288e (a)); Foreign Missions
Act of 1982 (22 U.S.C. 4301-4316) as amended.
PURPOSE: The information solicited on this form will be used to adjudicate requests for diplomatic exemption from taxes on utilities.
ROUTINE USES: The information provided on this form may be provided to other federal agencies for law enforcement, administrative or other
statutorily authorized purposes as covered under STATE 36, Security Records. This information also may be provided to the employing foreign
government or international organization.
DISCLOSURE: Providing this information is voluntary; Failure to provide the information requested on this form may result in denial of diplomatic
exemption from taxes on utilities.
Paperwork Reduction Act Statement
*Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time required for searching
existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final
collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments
on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: M/OFM, 3507 International Place NW,
Washington, DC 20008.
DS-98
Page 2 of 2
Privacy Act Statement
AUTHORITIES: The information is sought pursuant to Vienna Convention on Diplomatic Relations of 1961; Vienna Convention on Consular
Relations of 1963; Diplomatic Relations Act (22 U.S.C. 254a-e); International Organizations Immunities Act (22 U.S.C. 288e (a)); Foreign Missions
Act of 1982 (22 U.S.C. 4301-4316) as amended.
PURPOSE: The information solicited on this form will be used to adjudicate requests for diplomatic exemption from taxes on utilities.
ROUTINE USES: The information provided on this form may be provided to other federal agencies for law enforcement, administrative or other
statutorily authorized purposes as covered under STATE 36, Security Records. This information also may be provided to the employing foreign
government or international organization.
DISCLOSURE: Providing this information is voluntary; Failure to provide the information requested on this form may result in denial of diplomatic
exemption from taxes on utilities.
Paperwork Reduction Act Statement
*Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time required for searching
existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final
collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments
on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: M/OFM, 3507 International Place NW,
Washington, DC 20008.
DS-98
Page 2 of 2
Privacy Act Statement
AUTHORITIES: The information is sought pursuant to Vienna Convention on Diplomatic Relations of 1961; Vienna Convention on Consular
Relations of 1963; Diplomatic Relations Act (22 U.S.C. 254a-e); International Organizations Immunities Act (22 U.S.C. 288e (a)); Foreign Missions
Act of 1982 (22 U.S.C. 4301-4316) as amended.
PURPOSE: The information solicited on this form will be used to adjudicate requests for diplomatic exemption from taxes on utilities.
ROUTINE USES: The information provided on this form may be provided to other federal agencies for law enforcement, administrative or other
statutorily authorized purposes as covered under STATE 36, Security Records. This information also may be provided to the employing foreign
government or international organization.
DISCLOSURE: Providing this information is voluntary; Failure to provide the information requested on this form may result in denial of diplomatic
exemption from taxes on utilities.
Paperwork Reduction Act Statement
*Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time required for searching
existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final
collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments
on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: M/OFM, 3507 International Place NW,
Washington, DC 20008.
DS-98
Page 2 of 2
| File Type | application/pdf |
| File Title | DS-0098 |
| Author | ciupekra |
| File Modified | 2014-11-18 |
| File Created | 2014-11-18 |