Form Dr-350907 Draft - Local Insurance Premium Tax Special Fire Control Districts Notification Of Jurisdiction Change
ADVERTISEMENT
1
2DR-350907
Local Insurance Premium Tax
R. 10/13
Special Fire Control Districts
TC
Notification of Jurisdiction Change
Rule 12B-8.0016
Florida Administrative Code
Effective 01/14
All jurisdiction change requests must be submitted using the Department of Revenue’s website at:
Name of Fire Control District initiating change
Effective date of change NOTE:
Changes must be provided by September 3rd each year.
Case number
NOTE:
The case number is assigned by the Department’s address database once change records
are submitted. The database is available at:
Type of jurisdiction change
o
o
o
o
Street address correction
New address
Annexation
Other _____________________
o
o
Does this change affect another local jurisdiction?
Yes
No
If yes, enter affected jurisdiction ___________________________________
OFFICIAL AUTHORIZATION
Part A
Part B
Initiating jurisdiction
Affected jurisdiction
Name of authorizing official
Name of authorizing official (See Instructions - Step 4.)
Title
Title
Telephone
Fax
Telephone
Fax
E-mail
E-mail
I have reviewed the proposed jurisdiction changes for accuracy. I am an authorized
I have reviewed the proposed jurisdiction changes for accuracy. I am an authorized
representative of the Florida jurisdiction requesting these changes. I authorize the
representative of the Florida jurisdiction affected by these changes. I authorize the
Department of Revenue to modify the address/jurisdiction database to reflect these
Department of Revenue to modify the address/jurisdiction database to reflect these
changes.
changes.
Signature ________________________________________________________
Signature ________________________________________________________
Date _____________________________________________________________
Date _____________________________________________________________
Part C. Complete this part only if you are unable to obtain the written consent of the affected jurisdiction.
Affected jurisdiction
Name of authorizing official contacted
o
Method of contact (
check all that apply)
o
o
o
o
o
Telephone
Mail
E-mail
Fax
Other
I have contacted the authorizing official named above and have been unable to obtain a signature in Part B.
Signature of authorized representative of initiating jurisdiction _____________________________________________________________________________
____________________________________________________________________________________________________________________________________
FOR DOR USE ONLY
Date Received ___________________________
Worked By ______________________________
Action _________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dr-350907 - Local Insurance Premium Tax Special Fire Control Districts Notification Of Jurisdiction Change
Financial
Form Dr-700022 - Notification Of Jurisdiction Change For Local Communications Services And Local Insurance Premium Tax
Financial
Form Dr-700025 - Objection To Address/jurisdiction Database For Local Communications Services Tax And Local Insurance Premium Tax Service Address Assignment
Financial
Form Dr-700025 - Objection To Address-jurisdiction Database For Local Communications Services Tax And Local Insurance Premium Tax Service Address Assignment
Financial
Form Dr-700025 - Objection To Address/jurisdiction Database For Local Communications Services Tax And Local Insurance Premium Tax Service Address Assignment
Financial
Form Dr-700025 - Objection To Address/jurisdiction Database For Local Communications Services Tax And Local Insurance Premium Tax Service Address Assignment
Financial
Form Dr-189 Draft - Application For Fuel Tax Refund Municipalities, Counties And School Districts
Financial
Related Categories
Parent category: Financial