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

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

DR-843

03/00

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

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