Form Dr-5 - Application For A Consumer'S Certificate Of Exemption - 2017 Page 4
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4Application for a Consumer's
DR-5
R. 01/17
Certificate of Exemption
Rule 12A-1.097
Florida Administrative Code
Effective 01/17
Mail with Supporting Documentation to:
Account Management-Exemptions
Florida Department of Revenue
PO Box 6480
Tallahassee FL 32314-6480
Exemption category for which you are applying (check only one):
501(c)(3) Organization
Parent-Teacher Organization or Association
Community Cemetery
Political Subdivision
Credit Union
Religious Institution - physical place for worship
Fair Association
Religious Institution - transportation provider
Florida Retired Educators Association
Religious Institution - governing or administrative
Library Cooperative
School, College, or University
Nonprofit Cooperative Hospital Laundry
Veterans' Organization
Nonprofit Water System
Volunteer Fire Department
Organization Benefiting Minors
Federal Employer Identification Number (FEIN)
Legal Name of Organization or Political Subdivision
Business Phone
Street
State
ZIP
City
Alternate Phone
Mailing Address (If different than above)
City
State
ZIP
Name of Contact Person
Title
Email Address - Your email address is treated as confidential information (s. 213.053, F.S.), and is not subject to disclosure as public records (s. 119.071, F.S.).
Credit Union Charter Number - If you are applying as a credit union.
Your privacy is important to the Department. To protect your privacy, access to personal information about your organization is limited to the
person who has signed this Application for a Consumer's Certificate of Exemption. To ensure that information is not provided without your
consent, a written request from you is required if you wish to receive a secured email regarding this Application. If so, the Department will
send information regarding this Application using its secure email software. This software will require additional steps before you can access
the information. If you do not want to receive information by email, any information regarding this Application will be mailed to you.
I authorize the Florida Department of Revenue to send information regarding this Application for a Consumer's Certificate of Exemption
using the Department's secure email. I understand that this method requires additional steps to view the information provided.
I hereby attest that I am authorized to sign on behalf of the applicant organization described above. I further attest that, if granted, the
Consumer's Certificate of Exemption will only be used in the manner authorized for this organization under s. 212.08(6), (7), or 213.12(2), F.S.
Under penalties of perjury, I declare that I have read the foregoing application and that the facts stated in it are true.
Title
Signature
Print Name
Date
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Parent category: Financial