Form Dr-1 - Business Application (Page 4 of 4) in pdf

DR-1

Page 4

DOCUMENTARY STAMPS

Does your business include sales finalized by written agreements that do not require recording by

40.

the Clerk of the Court, but do require documentary stamps to be affixed?

------------------------------------------ Yes

If yes, answer the questions in this block.

41.

Is this application being completed to register your first location to collect documentary stamp tax? ................................... Yes

If no, and this application is for additional locations, please list name and address of each additional location. __________________________

_________________________________________________________________________________________________________________

42.

Do you anticipate five or more taxable transactions per month? ---------------------------------------------------------------------- Yes

43.

Do you anticipate your average monthly tax remittance to be less than $80 a month? --------------------------------------------- Yes

Owner, Partner, Officer Information

44.

List the primary owner or corporate officer first. Enter the name, social security number, home

address, and telephone number of the owners, partners, or corporate officers.

This application will not be processed without this information.

Name and Title

Social Security Number

Home Address

Telephone Number

–

45.

Business or Personal Banking Information:

Personal account

Business account

Bank name

Account number where tax will be deposited

Bank street address

City

State

ZIP

46.

Is your business location rented? -------------------------------------------------------------------------------------------------------- Yes

If yes, provide the following information:

Landlord or Owner’s Name: _____________________________________________________________________

Address: _____________________________________________________________________________________

City/State/ZIP: ________________________________________________________________________________

Telephone Number: ____________________________________________________________________________

Applicant Signature—This Application Cannot Be Processed If Not Signed by the Applicant

Under penalties of perjury, I declare that I have read the foregoing application and that the facts stated in it are true.

Signature of the business or real property owner, partner, or principal corporate officer

Date application signed

Print or type the name signed above

Title of signatory

Please note that any person (including employees, corporate directors, corporate officers, etc.) who is required to collect, truthfully account for, and

pay any sales taxes and willfully fails to do so shall be liable for penalties under the provisions of §213.29, Florida Statutes (F.S.). All information

provided by the applicant is confidential as provided in §213.053, F.S., and is not subject to Florida Public Records Law (§119.07, F. S.).

NOTE: After signing, mail completed application and applicable registration fee (DO NOT SEND CASH) to

FLORIDA DEPARTMENT OF REVENUE, 5050 W TENNESSEE ST, TALLAHASSEE, FL 32399-0100;

or mail or deliver to any Department of Revenue service center.

FOR DOR OFFICE USE ONLY

Documentary Stamp Tax

Gross Receipts Tax