Form Dbpr Abt-6008 - Application For Importer Or Broker Sales Agent (Page 3 of 7) in pdf

Are you an official with State police powers granted by the Florida Legislature?

Yes

If yes, provide details:

___________________________________________________________________________________

___________________________________________________________________________

NOTARIZATION STATEMENT

“I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and

837.06, Florida Statutes, that I have fully disclosed any and all parties financially and or contractually

interested in this business and that the parties are disclosed in Section 12 of this application. I further swear

or affirm that the foregoing information is true and correct.”

STATE OF___________________

COUNTY OF_________________

_________________________________________________

APPLICANT SIGNATURE

The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this _______Day

of______________, 20_____, By_____________________________________ who is ( ) personally known

to me OR ( ) who produced ______________________________________________as identification.

________________________________________________ Commission Expires: ___________________

Notary Public

(ATTACH ADDITIONAL COPIES AS NECESSARY)

*Social Security Number

Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a

Federal statute specifically requires it or allows states to collect the number. In this instance,

disclosure of social security numbers is mandatory pursuant to Title 42 United States Code,

Sections 653 and 654; and sections 409.2577, 409.2598, and 559.79, Florida Statutes. Social

Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D

child support agency to assure compliance with child support obligations. Social Security

numbers must also be recorded on all professional and occupational license applications and are

used for licensee identification pursuant to the Personal Responsibility and Work Opportunity

Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317. The State of Florida

is authorized to collect the social security number of licensees pursuant to the Social Security Act,

42 U.S.C. 405(c)(2)(C)(I). This information is used to identify licensees for tax administration

purposes.

Form Dbpr Abt-6008 - Application For Importer Or Broker Sales Agent Page 3