Form Dr-18 - Application For Amusement Machine Certificate Page 3
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4DR-18
Application for Amusement Machine Certificate
R. 03/06
Page 3
This application is used for the purpose of authorizing a location
OMITTING ANY INFORMATION WILL CAUSE DELAYS IN
to operate a specified number of coin-operated amusement
PROCESSING. If you need assistance with this application,
machines. Every registered sales tax dealer who is the “operator”
please call the Department’s Account Management Section at
of such machines must annually renew each location’s certificate
800-352-3671 or the nearest service center. If you have questions
with the Department of Revenue. This application must also be
regarding the taxation of coin-operated amusement machines, please
submitted when an operator wishes to operate more machines at a
call Taxpayer Services, Monday - Friday, 8 a.m. to 7 p.m., ET, at 800-
location than are listed on a previously issued Amusement Machine
352-3671. From the option menu, select Information on Taxes or Forms
Certificate (Form DR-18C). Every location where coin-operated
or the nearest service center. You may also find general information
amusement machines are in operation must display a certificate
and forms at
which authorizes operation of a specified number of amusement
This application and the required $30 per machine fee may be
machines. Each certificate must be renewed annually before July
delivered to the nearest Florida Department of Revenue service center
1st. The annual fee is $30 per machine.
or mailed to:
Refer to pages 1 and 2 for line-by-line instructions for completing this
Amusement Machine Certificate - Room 1-5600
application. Photocopies of the reverse side of this form may be used
Florida Department of Revenue
if needed. The original front page must always be included. This
5050 W Tennessee St
application must be completed in its entirety.
Tallahassee FL 32399-0156
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.
1.
Sales and use tax registration number
–
–
2.
Name of operator ____________________________________________________________________________________________________________
3.
Business name of operator ____________________________________________________________________________________________________
4.
Operator’s mailing address ____________________________________________________________________________________________________
City _______________________________________________________________State _________________ ZIP _______________________________
5a.
Daytime telephone number
( _________ ) _____________________________ 5b. E-mail ____________________________________________
PROvIDE THE INFORMATION REQUESTED ON THE REvERSE SIDE OF THIS FORM FOR MACHINE LOCATION(S).
6.
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: ____________Processed by: _____________ Date: ______________
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