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DR-700026

Local Government Authorization For

R. 10/13

Address Changes Described on Form DR-700025

Rule 12A-19.100

Florida Administrative Code

Effective 01/14

Refer to attached Form DR-700025 before completing this form.

Consent for Assigned Jurisdiction

Consent for Proposed Jurisdiction

Jurisdiction where address is now assigned

Proposed jurisdiction where address should be assigned

Name of authorizing official (contact person)

Telephone

Fax

Telephone

Fax

E-mail

I agree that the address(s) described on Form DR-700025 should

be assigned to the proposed jurisdiction and authorize the DOR to

change the Address/Jurisdiction Database.

I disagree that the address(s) described on Form DR-700025 should

be assigned to the proposed jurisdiction and do not authorize the

change.

I partially agree that the address(s) described on Form DR-700025

should be assigned to the proposed jurisdiction and authorize the

should be assigned to the proposed jurisdiction and authorize

DOR to change the database for the address(s) described below.

the DOR to change the database for address(s) described below.

(Describe the address(s) you agree should be changed to the

proposed jurisdiction. Attach additional pages if needed.)

I am an authorized representative of the jurisdiction.

Signature _________________________________________________

Date _____________________________________________________

INSTRUCTIONS

Only the official database contact person may sign as the authorized

Use the right portion of the form (Consent for Proposed Jurisdiction), if you

representative of the jurisdiction. For a list of official database contact persons,

are the contact person for the proposed jurisdiction where the address(s)

go to For a list of the local insurance

should be assigned. Check the appropriate box indicating your agreement,

premium tax contacts, go to

disagreement, or partial agreement with the reason for the objection indicated

in Part C of Form DR-700025. For partial agreements, describe the parts of

Review the address(s) described on Form DR-700025, Part B.

the address(s) you agree with. Attach additional sheets if necessary.

Use the left portion of the form (Consent for Assigned Jurisdiction), if you are

Sign, date, and return this form to the Department of Revenue. Do not

send the form to the proposed or assigned jurisdiction.

the contact person for the jurisdiction where the address(s) is now assigned.

Mail to: Florida Department of Revenue

For overnight or other delivery requiring a

Or Fax to: 850-921-4711

street address, use:

Local Government Unit

For more information, call the Department’s

PO Box 6530

Florida Department of Revenue

Local Government Unit at 850-717-6630 or

Tallahassee, FL 32314-6530

Local Government Unit

e-mail to:

Mail Stop 1-4400

5050 W Tennessee St

Tallahassee, FL 32399-0161

FOR DOR USE ONLY

Tracking number ____________________________________________________________

Date _______________________________

Form Dr-700026 - Local Government Authorization For Address Changes Described On Form Dr-700025

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