Form Dr-842 - Seller'S Application For Transferee Liability Certificate

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DR-842
Seller’s Application for Transferee
R.10/10
Liability Certificate
The dealer referenced below, has sold or is selling his or her business or stock of goods, and
is applying for a Transferee Liability Certificate for the period _________________ through ________________.
Name of Selling Dealer: ________________________________________________
Mailing Address: ______________________________________________________
City, State, ZIP: _______________________________________________________
Business Partner Number: ____________________
When the audit is complete, send the certificate to:
Name of Purchaser: __________________________________________
Mailing Address:
__________________________________________
City, State, ZIP:
___________________________________________
I give the Department permission to include in the certificate, information about the requested audit
which you may not, without permission, disclose without violating the confidentiality requirements of
s. 213.053, Florida Statutes.
Signature of Owner or Representative of Selling Dealer:
_____________________________________________
Name of Owner or Representative:
_____________________________________________
(Please print)
Telephone Number:
____________________________________________
Mail to: General Tax Administration Program
Compliance Support Process
Post Office Box 5139
Tallahassee, Fl 32314-5139
Phone: 850-617-8565
Fax: 850-488-0325

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