Form Dr-26rp - Florida Neighborhood Revitalization Program

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DR-26RP
Florida Neighborhood
R. 10/09
Revitalization Program
Rule 12A-1.097
Florida Administrative Code
Effective 06/10
(If you are applying for an enterprise zone - building materials or business equipment
refund, please obtain an EZ-M or EZ-E from your local enterprise zone coordinator.)
1. Please indicate the type of refund you are applying for by clearly marking the appropriate boxes:
❏ Enterprise (empowerment) zone
❏ Urban high crime area
(This application must be verified and signed by your local
❏ Housing project
enterprise zone coordinator.)
❏ Mixed-use project
❏ Single family home
❏ Housing project
❏ Brownfield area
❏ Mixed-use project
❏ Housing project
❏ Mixed-use project
❏ Front Porch Florida Community
(This application must be verified and signed by your Front
❏ Urban infill and redevelopment area
Porch Florida council chair.)
❏ Housing project
❏ Single family home
❏ Mixed-use project
❏ Housing project
❏ Mixed-use project
2. Zone number, area number, or name: ______________________________________________________________________
(For enterprise or empowerment zones ONLY - please have the local enterprise zone coordinator complete #3 of
this application verifying the construction is inside the boundaries of an enterprise or empowerment zone)
3.
Florida EZ Number: EZ- _____________________________
4.
Owner’s name: ______________________________________________________________________________________________________
5.
Owner’s social security* or FEI number: ________________________________________________________________________________
6.
Mailing address: ____________________________________________________________________________________________________
____________________________________________________________________________________________________________________
city, state, ZIP: ______________________________________________________________________________________________________
7.
Property address: ____________________________________________________________________________________________________
____________________________________________________________________________________________________________________
city, state, ZIP: ______________________________________________________________________________________________________
8.
Assessment roll parcel number: _______________________________________________________________________________________
9.
Building permit number: ______________________________
Inspector’s name: ________________________________________
Phone number: _______________________________________
Fax number: ______________________________________________
10. Date of certificate stating improvements are substantially completed: ______/______/______
I hereby affirm under penalty of perjury that all of the above statements are true and correct to the best of my knowledge and belief.
Sworn to and subscribed before me this ___________ day of _________ ,_________.
____________________________________________________
_________________________________________________________
(Signature of owner)
(Date)
____________________________________________________
_________________________________________________________
(Signature of enterprise zone coordinator)
(Date)

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