Form Dr-18r Draft - Amusement Machine Certificate Renewal Application printable pdf download

DR-18R

Amusement Machine Certificate

R. 03/17

Renewal Application

Rule 12A-1.097

Florida Administrative Code

Effective 03/17

Our records indicate that you are the holder of an Amusement Machine Certificate(s) (Form DR-18C) that will expire on June 30.

Florida law requires every business location that operates amusement machines display an Amusement Machine Certificate. A penalty

of $250 per machine may be imposed on an operator who fails to obtain and display the required Amusement Machine Certificate.

The Previously Registered Machine Location Worksheet on the following page(s) contains a listing of your Amusement Machine

Certificates for each of your registered locations.

To complete the certificate renewal process:

• Review all information on the Previously Registered Machine Location Worksheet. Make any necessary changes.

• If you have additional machines to add that are not previously listed, an Additional Amusement Machine Location Worksheet

is provided. To complete this worksheet, you must have an active sales and use tax Certificate of Registration (Form DR-11)

for each county in which you operate machines. If you do not have a sales tax number for each county where your machines

are located for operation, you can register to collect and report tax through our website at or by

completing a paper Florida Business Tax Application (Form DR-1).

• Place worksheet totals in the summary box on each page and total all pages in the Grand Total box below.

• Attach a check or money order, payable to Florida Department of Revenue, for the registration fee ($30 per machine). Do not

send cash.

• Return this signed renewal application and your payment to:

If you need more information or have questions,

call Taxpayer Services at 850-488-6800,

Florida Department of Revenue

Monday through Friday (excluding holidays).

Amusement Machine Certificate - MS 1-5730

5050 W Tennessee St

Tallahassee FL 32399-0160

Grand Total - Summary of Fees from all pages

Total # of Locations ______ Total # of Machines: _________x $30 per machine = Total Fee Due: $ ____________________

Under penalties of perjury, I certify that I have read this application and the facts stated in it are true. I understand that a new

certificate must be obtained and additional fees are due if I wish to operate more amusement machines than are authorized

by the certificates issued under this application.

_____________________________________________________________________________

_____________________

A uthorized signature of operator or operator’s authorized representative

Date

_____________________________________________________________________________

Print or type the signature above

For DOR Office Use Only

No. of locations: ____________ No. of machines: ___________ Amount paid: ______________ Processed by: ______________________ Date: ______________

Form Dr-18r Draft - Amusement Machine Certificate Renewal Application