Form Dr-1 - Florida Business Tax Application (Page 9 of 10) in pdf

DR-1

R. 01/15

Page 9

51. Choose your filing/payment method:

Pay Electronically (select one):

ACH-Debit (e-check)

File Electronically

ACH-Credit

ACH-Debit (e-check) is the action taken when the Department’s bank withdraws a tax payment from the taxpayer’s bank account upon the taxpayer’s

authorization; the taxpayer’s bank account is debited.

ACH-Credit is the action taken when the taxpayer’s bank transfers a tax payment to the Department’s bank account; the Department’s account is credited.

This is not a credit card payment.

52. Banking Information (not required for ACH-Credit payment method):

Bank/financial institution name:

Account type:

Business, or

Checking, or

Personal

and

Savings

Bank account number:

Bank Routing Number:

Note: Due to federal security requirements, we cannot process international ACH transactions. If any funding for payments comes from financial institutions

located outside the US or its territories, please contact us to make other payment arrangements. If you are unsure, please contact your financial institution.

53. Enrollee Authorization and Agreement

This is an Agreement between the Florida Department of Revenue, hereinafter “the Department,” and the business entity named herein, hereinafter “the Enrollee,” entered

into according to the provisions of the Florida Statutes and the Florida Administrative Code.

By completing this agreement and submitting this enrollment request, the Enrollee applies and is hereby authorized by the Department to file tax returns and reports,

make tax and fee payments, and transmit remittances to the Department electronically. This agreement represents the entire understanding of the parties in relation to the

electronic filing of returns, reports, and remittances.

The same statute and rule provisions that pertain to all paper documents filed or payments made by the Enrollee also govern an electronic return, or payment initiated

electronically according to this agreement.

I certify that I am authorized to sign on behalf of the business entity identified herein, and that all information provided in this document has been personally reviewed by

me and the facts stated in it are true. According to the payment method selected above, I hereby authorize the Department to present debit entries into the bank account

referenced above at the depository designated herein (ACH-Debit), or I am authorized to register for the ACH-Credit payment privilege and accept all responsibility for the

filing of payments through the ACH-Credit method.

Signature: _ ______________________________________________________ Title: ____________________________________

Date: ______________________

Printed name: _______________________________________________________________________________________________

Second Signature: ________________________________________________ Title: ____________________________________

Date: ______________________

(If account requires two signatures)

Printed name: _______________________________________________________________________________________________

Section K - Applicant Acknowledgement, Declaration and Signature

Registrant’s

Responsibilities – You must initial next to each responsibility listed below to indicate that you have read, acknowledge, and understand each one. Your

application will be rejected if any part of this section is left blank.

______

I understand it is my responsibility to notify the Department of Revenue of any changes of business structure, activities, location, mailing address or contact

information.

______

I understand that any person who is required to collect, truthfully account for, and pay any tax, surcharge, or fee, and willfully fails to do so shall be personally

liable for penalties and twice the amount of tax, under the provisions of s. 213.29, F.S.

In addition to any other penalties provided by law, including civil penalties, I understand it is a criminal offense to:

______

Fail or refuse to register (a late registration fee or penalty may also be imposed).

______

Not timely file a tax return or report.

______

Underreport a tax, surcharge or fee liability on a return or report filed.

______

Fail or refuse to collect a required tax, surcharge or fee.

______

Not remit a collected tax, surcharge or fee.