Form Dr-142 - Solid Mineral Severance Tax Return Page 9

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*** Detach Coupon ***
DR-142ES
Florida Department of Revenue
R. 01/13
Declaration/Installment Payment of Estimated Solid Mineral Severance Tax
Handwritten Example
Typed Example
Installment
#_____
0 1 2 3 4 5 6 7 8 9
0123456789
Use black ink.
FEIN
Taxable
M
M
D
D Y
Y
Year End
Name
Installment Payment Amount
Address
(See reverse side)
City/St/ZIP
US DOLLARS
CENTS
,
,
Check here if you transmitted
Office use
M
M
D
D Y
Y
Do Not Write Below this Line.
funds electronically.
only
Make checks payable and mail to:
FLORIDA DEPARTMENT OF REVENUE
9100 0 99999999 0013042033 4 3999999999 0000 2
5050 W TENNESSEE ST
TALLAHASSEE FL 32399-0150
*** Detach Coupon ***
DR-142ES
Florida Department of Revenue
R. 01/13
Declaration/Installment Payment of Estimated Solid Mineral Severance Tax
Handwritten Example
Typed Example
Installment
#_____
0 1 2 3 4 5 6 7 8 9
0123456789
Use black ink.
FEIN
Taxable
M
M
D
D Y
Y
Year End
Name
Installment Payment Amount
Address
(See reverse side)
City/St/ZIP
US DOLLARS
CENTS
,
,
Check here if you transmitted
Office use
M
M
D
D Y
Y
Do Not Write Below this Line.
funds electronically.
only
Make checks payable and mail to:
FLORIDA DEPARTMENT OF REVENUE
9100 0 99999999 0013042033 4 3999999999 0000 2
5050 W TENNESSEE ST
TALLAHASSEE FL 32399-0150
*** Detach Coupon ***
DR-142ES
Florida Department of Revenue
R. 01/13
Declaration/Installment Payment of Estimated Solid Mineral Severance Tax
Handwritten Example
Typed Example
Installment
#_____
0 1 2 3 4 5 6 7 8 9
0123456789
Use black ink.
FEIN
Taxable
M
M
D
D Y
Y
Year End
Name
Installment Payment Amount
Address
(See reverse side)
City/St/ZIP
US DOLLARS
CENTS
,
,
Check here if you transmitted
Office use
M
M
D
D Y
Y
funds electronically.
Do Not Write Below this Line.
only
Make checks payable and mail to:
FLORIDA DEPARTMENT OF REVENUE
9100 0 99999999 0013042033 4 3999999999 0000 2
5050 W TENNESSEE ST
TALLAHASSEE FL 32399-0150

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