Form Dr-309636 Draft - Terminal Operator Information Return Page 3

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00002
DR-309636
Mail To:
Terminal Operator
Florida Department of Revenue
R. 01/14
5050 W Tennessee St
Information Return
Page 3
Tallahassee FL 32399-0165
2018
For Calendar Year:
Check here if filing a supplemental return
FEIN:
License Number:
920002018999900900270361300000000100002
Collection Period Ending:
DOR USE ONLY
POSTMARK OR HAND-DELIVERY DATE
Return Due By
Late After
Complete Reverse Side of Return First
Name of Terminal
Location of Terminal
IRS Terminal Code Number
Under penalty of perjury, I declare that I have read this return and the facts stated in it are true.
_______________________________________________________________________________________________________________________
Signature of Terminal Operator
Title
Date
_______________________________________________________________________________________________________________________
Name of Preparer (Print)
Signature of Preparer
Telephone Number
FEIN
Date

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