Form Dr-350907 - Local Insurance Premium Tax Special Fire Control Districts Notification Of Jurisdiction Change
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2DR-350907
Local Insurance Premium Tax
R. 10/06
Special Fire Control Districts
TC
Notification of Jurisdiction Change
Mail to:
LOCAL GOVERNMENT UNIT
FLORIDA DEPARTMENT OF REVENUE
PO BOX 6530
TALLAHASSEE FL 32314-6530
All jurisdiction change requests must be submitted via the Department of Revenue’s Internet site at
Competent evidence for the jurisdiction change described below must be submitted with this form. Changes submitted without filing
this form and the proper documentation will not be considered for modification of the address/jurisdiction database.
Name of Fire Control District initiating change
Effective date of change NOTE:
Changes must be provided by September 3rd each year.
Case number
NOTE:
The case number is assigned by the Department’s address database once
change records are submitted. The database is available at
Type of jurisdiction change
❏
❏
❏
❏
Street address correction
New address
Annexation
Other _____________________
❏
❏
Does this change affect another local jurisdiction?
Yes
No
If yes, enter affected jurisdiction ___________________________________
OFFICIAL AUTHORIZATION
Part A
Part B
Initiating jurisdiction
Affected jurisdiction
Name of authorizing official
Name of authorizing official (See Instructions - Step 4.)
Title
Title
Telephone
Fax
Telephone
Fax
E-mail
E-mail
I have reviewed the proposed jurisdiction changes for accuracy. I am an authorized
I have reviewed the proposed jurisdiction changes for accuracy. I am an authorized
representative of the Florida jurisdiction requesting these changes. I authorize the
representative of the Florida jurisdiction affected by these changes. I authorize the
Department of Revenue to modify the address/jurisdiction database to reflect these
Department of Revenue to modify the address/jurisdiction database to reflect these
changes.
changes.
Signature ________________________________________________________
Signature ________________________________________________________
Date _____________________________________________________________
Date _____________________________________________________________
Part C. Complete this part only if you are unable to obtain the written consent of the affected jurisdiction.
Affected jurisdiction
Name of authorizing official contacted
✓
Method of contact (
check all that apply)
❏
❏
❏
❏
❏
Telephone
Mail
E-mail
Fax
Other
I have contacted the authorizing official named above and have been unable to obtain a signature in Part B.
Signature of authorized representative of initiating jurisdiction _____________________________________________________________________________
FOR DOR USE ONLY
Date Received ___________________________
Worked By ______________________________
Action _________________________________
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