Form Dr-18 - Application For Amusement Machine Certificate

DR-18

R. 02/00

Page 3

Application for Amusement Machine Certificate

This application is for the purpose of authorizing a location to operate a specified number of coin-operated amusement

machines. Every registered sales tax dealer, who is the “operator” of such machines must annually renew each location’s

certificate with the Department of Revenue. This application must be alsosubmitted when an operator wishes to operate more machines at a

location than are listed on a previously issued Amusement Machine Certificate (Form DR-18C). Every location where coin-operated

amusement machines are in operation must display a certificate, which authorizes operation of a specified number of amusement

machines. Each certificate must be renewed annually before July 1st. The annual fee is $30 per machine.

Refer to the line-by-line instructions on Form DR-18IN for completing this application. Photocopies of the reverse side of this form may be

used if needed. The original front page must always be included. This application must be completed in its entirety. OMITTING ANY

INFORMATION WILL CAUSE DELAYS IN PROCESSING. If you need assistance with this application, please call the Department’s

Registration Section at 850-488-9750. If you have questions regarding the taxation of coin-operated amusement machines, please call

Taxpayer Services, Monday - Friday, 8 a.m. to 5 p.m., ET, at 1-800-352-3671 (in Florida only). From the option menu, select Information on

Taxes or Forms . Or, you may call 850-922-4824.

This application and the required $30 per machine fee may be delivered to the nearest Florida Department of Revenue Service Center or

mailed to:

Application for Amusement Machine Certificate (DR-18)

FLORIDA DEPARTMENT OF REVENUE

5050 W TENNESSEE STREET

TALLAHASSEE FL 32399-0100

Amusement Machine Operator Information

Refer to the instructions to determine whether you are the “operator” of the amusement machines on location and are

required to submit this application, pay the per-machine fees, and remit the tax on the machines’ use and/or lease.

Sales and Use Tax Registration Number: ______________ - ____________ - ______________________ - ______________

Name of Operator: ______________________________________________________________________________________

Business Name of Operator: ______________________________________________________________________________

Operator’s Mailing Address: ______________________________________________________________________________

City _____________________________________________________ State ______________ Zip _____________________

Daytime Telephone Number: ( ________ ) ________________________

PROVIDE THE INFORMATION REQUESTED ON THE REVERSE SIDE OF THIS FORM FOR MACHINE LOCATION(S)

Certification by operator or operator’s authorized representative

I hereby certify that the information provided on this application is, to the best of my knowledge and belief, complete, true and correct,

and that each certificate obtained with this application will be conspicuously displayed on the premises whose location(s) appear(s)

herein. I understand that additional fees are due and a new certificate must be obtained when I wish to operate more machines than

are authorized by the certificate(s) issued pursuant to this application.

_____________________________________________________________________________

________________________

Authorized Signature of Operator or Operator’s Authorized Representative

Date

_____________________________________________________________________________

Print or Type the Signature Above

for DOR office use only

No. of Locations: _____ No. of Machines: ______ Amount Paid: ______________ No. Certificates Issued: ______ Date: _____

Form Dr-18 - Application For Amusement Machine Certificate - 2000

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