Form Dr-157a - Assignment Of Time Deposit


Assignment of Time Deposit
R. 09/11
PO BOX 6480
Rule 12B-5.150
TALLAHASSEE, FL 32314 - 6480
Florida Administrative Code
Please complete and submit an original form for each fuel product type or taxable pollutant. This form must be executed
by the financial institution which holds the assigned time deposit. An applicant cannot be issued a fuel license by the
Department until the proper security is submitted. An importer’s bond is required in addition to a wholesaler’s bond
pursuant to Rule 12B-5.030, F.A.C. If further information is needed, please contact Account Management at 800-352-3671.
For value received, ______________________________________________________________ as assignor, assigns to the
(Name of applicant)
Florida Department of Revenue as assignee all of its rights, titles, and interest in and to the principal sum of the certificate
of deposit, certificate number _____________________________________________, issued to the undersigned for a time
period of ______ months by __________________________________________________________________________________
(Financial institution name)
located at ___________________________________________________________________________________ as Depository
(Financial institution address)
(Financial institution FEIN)
Interest or dividends on such principal sum shall be credited and paid monthly to the assignor. This assignment includes
any substitutions, renewals, and additions to the account.
This assignment is made as security in lieu of the bond required by Chapter 206, Florida Statutes, on fuel taxes payable to
the Florida Department of Revenue and shall continue in force until released and discharged by the assignee, as provided by
law. The assignor is engaged in business subject to the Florida Statute identified below: (Please check the appropriate box.)
( ) Motor fuel pursuant to Chapter 206, F.S.
( ) Alternative fuel pursuant to Chapter 206, F.S.
( ) Diesel fuel pursuant to Chapter 206, F.S.
( ) Importer’s bond pursuant to section 206.051, F.S.
( ) Aviation fuel pursuant to Chapter 206, F.S.
( ) Pollutants tax pursuant to Chapter 206, F.S.
Assignee is hereby authorized to charge against the above principal of time deposit account any and all fuel taxes which
have been or may be incurred after __________________ together with any and all penalties and interest thereon.
Assignee may not by any inference or right charge against this time deposit account any tax, penalty, interest, or any
other charge pertaining to the assignor’s operations prior to ________________ .
Depository must pay the full principal amount to the assignee upon demand and such payment shall constitute an
acquittance of depository. The depository shall not pay any portion of the principal balance to the assignor until all
obligations under Chapter 206, F.S., have been met and verified in writing by the assignee.
This Assignment of Time Deposit shall be effective as of the __________ day of ______________________ , ____________ .
Imprint Corporate Seal here:
Signed by: __________________________________________
(Authorized signature of assignor)
Date: _______________________________________________
Title: _______________________________________________
Acknowledgement of Depository: The signatures as shown above compare correctly with our files. The above
assignment will be honored and has been properly recorded on our ledger. The present balance is $ _________________ .
(Officer signature)
For Department of Revenue Use Only
Accepted: _____________________ By ___________________________________ Account No.: ________________________


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