Looking for a Florida Department Of Revenue Forms And Templates? Download it for free!

Form Gt-400210 - Registration Information Sharing And Exchange (Rise) Program Level-One Agreement Page 4

GT-400210

R. 01/16

Page 4

RISE Attachment A

for

Level-one Agreement

Name of Local Government: _______________________________________________________________________

Signer of Agreement:

Name: ______________________________

Title: ________________________________

Mailing address: _______________________

Email address: ________________________

Phone:

_____________________________

Administrative contact:

Name: ______________________________

Title: ________________________________

Mailing address: _______________________

Email address: ________________________

Phone: ______________________________

Data processing contact:

Name: ______________________________

Title: _______________________________

Mailing address: ______________________

Email address: ________________________

Phone: ______________________________

Information sharing frequency (select one):

____ Monthly

____ Quarterly

Type of Computer System: ________________________________________

Method of Data Transmission will be Secure Email.

NOTE: Prior approval must be obtained in writing from the Department for use of other than secure email

medium for data transmission.

Application should be made to:

RISE Coordinator

Revenue Accounting

Mail Stop 1-3600

5050 W Tennessee Street

Tallahassee FL 32399-0136

Defined area and/or boundaries for data: List all applicable ZIP code(s), and/or county code(s).

_________________________________________________________________________________________________

Authorized signature:_____________________________________ Date:_______________________________________

Form Gt-400210 - Registration Information Sharing And Exchange (Rise) Program Level-One Agreement Page 4