Form Dr-18 - Application For Amusement Machine Certificate

Application for Amusement Machine Certificate

DR-18

R. 01/16

Initial Application

Rule 12A-1.097

Florida Administrative Code

Add Locations or Machines

Effective 01/16

Annual Renewal Application

Amusement Machine Operator Information:

Business Partner Number - This number is located

Business Operator Identification Number - Provide the Federal

on the back of your Certificate of Registration

Employer Identification Number (FEIN) of the business operator or

(Form DR-11).

Social Security Number (SSN)* of the operator.

Business Partner Number:

FEIN:

SSN*:

*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.

Name of operator _____________________________________________________________________________________________

Business name of operator ____________________________________________________________________________________

Operator’s mailing address_____________________________________________________________________________________

City _______________________________________________ State _________________________ ZIP _______________________

Telephone Number: ( ______) _____________________ Email Address: ______________________________________________

(Your email address is treated as confidential information [section 213.053, Florida Statutes], and is not subject to

disclosure of public records [section 119.071, Florida Statutes].)

Under penalties of perjury, I certify that I have read this application and the facts stated in it are true. I understand that

a new certificate must be obtained and additional fees are due if I wish to operate more amusement machines than are

authorized by the certificates issued under this application.

________________________________________________________________

______________________________

Authorized signature of operator or operator’s authorized representative

Date

________________________________________________________________

Print or type the signature above

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

service center or mailed to:

Note: Your check or money order is for the total amount of

Florida Department of Revenue

Amusement Machine Certificate - MS 1-5730

machine fees for all locations ($30 times the total number

5050 W Tennessee St

of machines). If not, your application and payment will be

Tallahassee FL 32399-0160

returned to you without processing.

Amusement Machine Location Information

Be Sure To:

Enter your county or location sales and use tax Certificate

• Indicate the type of application you are submitting:

of Registration number for this location. If this is your first

› Initial Application › Adding locations or machines

application for a certificate for machines operated at this

› Annual Renewal Application

location, check the box for “New Location.” If you are adding

• Obtain a sales and use tax Certificate of

machines to a previously issued certificate, check the box for

Registration number for each county in which you

“Change Amusement Machine Certificate” and enter the

will operate amusement machines before you

number of additional machines that will be operated at this

complete this application.

location. If you did not receive a renewal application from the

• If you have a consolidated sales tax account, be

Department and you are using this application to renew your

sure to enter your county sales tax certificate

certificate, check the box “Annual Renewal.” Be sure to

number for the county in the Amusement Machine

enter the maximum number of machines to be operated

Location Information, not your consolidated sales

at each location. Multiply the number of machines by $30 to

tax account number.

compute the fee due for each location.

For DOR office use only

No. of locations: ________ No. of machines: ________ Amount paid: ___________ Processed by: ____________ Date: ______________

Form Dr-18 - Application For Amusement Machine Certificate - 2016

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