Form Dr-248 - Alternative Fuel Use Permit Application, Renewal, And Decal Order Form - 2012

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DR-248
2012 Alternative Fuel Use Permit
R. 11/11
Application, Renewal, and Decal Order Form
Rule 12B-5.150
Florida Administrative Code
Effective Date: 01/12
Permit Number:
For Period Ending:
FEIN or Social Security Number:
Enter owner name, location address, and mailing address.
Computation of 2012 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
196.90
268.50
375.90
196.90
268.50
375.90
196.90
268.50
375.90
268.50
375.90
196.90
196.90
268.50
375.90
196.90
268.50
375.90
196.90
268.50
375.90
196.90
268.50
375.90
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 (SSNs) are used by the Florida Department of Revenue as unique identifiers for the administration of Florida’s taxes. SSNs
obtained for tax administration purposes are confidential under sections 213.053 and 119.071, Florida Statutes, and not subject to disclosure as public records.
Collection of your SSN is authorized under state and federal law. Visit our Internet site at and select “Privacy Notice” for more
information regarding the state and federal law governing the collection, use, or release of SSNs, including authorized exceptions.

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