Form Dr-18 - Application For Amusement Machine Certificate - 2001 Page 3
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3DR-18
R. 06/01
Application for Amusement Machine Certificate
Page 3
This application is used for the purpose of authorizing a location to
OMITTING ANY INFORMATION WILL CAUSE DELAYS IN
operate a specified number of coin-operated amusement machines.
PROCESSING. If you need assistance with this application,
Every registered sales tax dealer who is the “operator” of such
please call the Department’s Registration Section at
machines must annually renew each location’s certificate with the
850-488-9750. If you have questions regarding the taxation of
Department of Revenue. This application must also be submitted
coin-operated amusement machines, please call Taxpayer
when an operator wishes to operate more machines at a location
Services, Monday - Friday, 8 a.m. to 7 p.m., ET, at 1-800-352-3671
than are listed on a previously issued Amusement Machine
(in Florida only). From the option menu, select Information on
Certificate (Form DR-18C). Every location where coin-operated
Taxes or Forms . Or, you may call 850-922-4824.
amusement machines are in operation must display a certificate,
which authorizes operation of a specified number of amusement
This application and the required $30 per machine fee may be
machines. Each certificate must be renewed annually before
delivered to the nearest Florida Department of Revenue service
July 1st. The annual fee is $30 per machine.
center or mailed to:
Application for Amusement Machine Certificate (DR-18)
FLORIDA DEPARTMENT OF REVENUE
Refer to pages 1 and 2 for line-by-line instructions for completing
5050 W TENNESSEE STREET
this application. Photocopies of the reverse side of this form may
TALLAHASSEE FL 32399-0100
be used if needed. The original front page must always be
included. This application must be completed in its entirety.
Amusement Machine Operator Information
Refer to the instructions to determine whether you are the “operator” of the amusement machines on location and are
required to submit this application, pay the per-machine fees, and remit the tax on the machines’ use and/or lease.
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1.
Sales and use tax registration number
2.
Name of operator _____________________________________________________________________________________________
3.
Business name of operator _____________________________________________________________________________________
4.
Operator’s mailing address _____________________________________________________________________________________
City _____________________________________________________ State ______________ ZIP ___________________________
5.
Daytime telephone number
( ________ ) ________________________
PROVIDE THE INFORMATION REQUESTED ON THE REVERSE SIDE OF THIS FORM FOR MACHINE LOCATION(S).
6.
Certification by operator or operator’s authorized representative:
I hereby certify that the information provided on this application is, to the best of my knowledge and belief, complete, true and correct,
and that each certificate obtained with this application will be conspicuously displayed on the premises whose location(s) appear(s)
herein. I understand that additional fees are due and a new certificate must be obtained when I wish to operate more machines than
are authorized by the certificate(s) issued pursuant to this application.
_____________________________________________________________________________
________________________
Authorized signature of operator or operator’s authorized representative
Date
_____________________________________________________________________________
Print or type the signature above
For DOR office use only
No. of locations: ________ No. of machines: ________ Amount paid: ____________ No. certificates issued: _______ Date: ____________
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