Form Dr-248 - Alternative Fuel Use Permit Application, Renewal, And Decal Order Form - 2009

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DR-248
2009 Alternative Fuel Use Permit
R. 03/09
Application, Renewal, and Decal Order Form
Rule 12B-5.150
Florida Administrative Code
Effective 04/09
Permit Number:
For Period Ending:
FEIN or Social Security Number:
Enter owner name, location address, and mailing address
Computation of 2009 Decal Fee(s)
Name of
Class A
Class B
Class C
Class A + B + C
county in
which the
vehicle is
Rate
x Number
= Class Total
Rate
x Number
= Class Total
Rate
x Number
= Class Total
Total
Annual
predominately
of Vehicles
of Vehicles
of Vehicles
vehicles
Fees
used
194.70
265.50
371.70
194.70
265.50
371.70
194.70
265.50
371.70
265.50
371.70
194.70
194.70
265.50
371.70
194.70
265.50
371.70
194.70
265.50
371.70
194.70
265.50
371.70
Total
+
=
+
Decals
Annual
$
$
$
+
=
+
Fees
x
Proration Factor
(see Lines 9 and 10 of instructions)
$
Total Fees Due
Print or type applicant’s name _____________________________________________________
Title ____________________________________Contact phone number ___________________________
I certify that this application has been examined by me and to the best of my knowledge and belief is true and complete.
Signature of applicant ____________________________________________________________________
Note: Social security numbers are used by the Florida Department of Revenue as unique identifiers for the administration of
Florida’s taxes. Social security numbers obtained for tax administration purposes are confidential under sections 213.053 and
119.071, Florida Statutes, and not subject to disclosure as public records.

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