Form Dr-843 - Purchaser'S Application For Transferee Liability Certificate


General Tax Administration
Child Support Enforcement
Purchaser’s Application for Transferee
Property Tax Administration
Administrative Services
Liability Certificate
Information Services
Jim Zingale
Executive Director
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: ________________________________________________
Mailing Address: ______________________________________________________
City, State, Zip: _______________________________________________________
Sales and Use Tax Registration Number: ___-___-___________-___
FEIN/SSN: ______________________
It is requested that the certificate be based on an audit of the selling dealer’s records of transactions during the period that
began: __________________________ and ended: ______________________________.
Name of Purchaser: _______________________________________ Telephone Number: _____________________
Signature of Purchaser: ____________________________________
The foregoing instrument, including the attached documents, if any, were acknowledged before me this day of
_____________________, by ___________________________, who is acting solely on his or her own behalf, 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 ________________________________________.
(Signature of notary)
( print, type or stamp name of notary)
Personally know ________
Or produced identification _____
Type of identification produced _________________
Should you have any questions, or need assistance in completing your application, please call 850-921-8737.
Mail to: General Tax Administration Program
Compliance Support Process
Post Office Box 5139
Tallahassee, Fl 32314-5139
Fax: 850-488-0325
Tallahassee, Florida 32399-0100


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Parent category: Financial