Form Dr-843 - Purchaser'S Application For Transferee Liability Certificate
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1DR-843
STATE OF FLORIDA
R. 10/95
DEPARTMENT OF REVENUE
TALLAHASSEE, FLORIDA 32399-0100
General Tax Administration
Child Support Enforcement
Property Tax Administration
L. H. Fuchs
Administrative Services
Executive Director
Information Services
Florida Department of Revenue
Purchaser’s Application for Transferee Liability Certificate
The undersigned, having purchased a business or stock of goods (as evidenced by the document
attached hereto and made a part hereof), hereby applies for a transferee liability certificate relating to the
following selling dealer:
_______________________________________
_____________________________________
(name of selling dealer)
(sales and use tax registration number)
_______________________________________
_____________________________________
(mailing address of selling dealer)
(FEI number)
___________________________________________________________________________________________
(city, state, zip code)
It is requested that the certificate be based on an audit of the selling dealer’s records of transactions
during the period that began:
________________________ , 19 ________
and ended: ________________________ , 19 _________
_____________________________________
(signature of applicant)
For: _____________________________________
(name of purchaser)
State of Florida
County of ______________________________
The foregoing instrument, including the attached documents, if any, were acknowledged before me
this day of _______________________ , 19 ______ , by ______________________________ , who is
acting solely on his or her own behalf, and who, if acting in a representative capacity, further
acknowledges the type of authority through which this representation is made as, (example: officer,
trustee, attorney in fact) _______________________________ for (name of person or entity on behalf
of whom this instrument was executed) ___________________________________________________ .
Witness my hand and official seal, this ______________ day of ____________________ ,19 _________ .
_________________________________
(signature of notary)
_________________________________________
(print, type or stamp name of notary)
Mail to:
General Tax Administration Program
personally known _______
Compliance Support Process
or produced identification _______
Post Office Box 5139
type of identification produced _________________________
Tallahassee FL 32314-5139
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