Form Dr-156 - Florida Fuel Or Pollutants Tax Application (Page 10 of 19) in pdf

Form Dr-156 - Florida Fuel Or Pollutants Tax Application Page 10

DR-156

R. 01/18

Page 7

47. Has your corporation, officers, or any affiliated entities ever been part of a bankruptcy proceeding? If yes, provide specific

case details.

48. Has your corporation, officers, or any affiliated entities now or within the past 10 years been involved in any litigation or fuel

tax issues in Florida or any other state? If so, provide details.

49. Who has signatory authority on the business bank accounts?

Affidavit of Applicant(s)

I, the undersigned individual(s), or if a corporation for itself, its officers, and directors, hereby swear or affirm under penalty of

perjury as provided in section 837.06, Florida Statutes, that I am duly authorized to make the foregoing application and that the

application and all attachments are true and correct representation(s) of the premises to be licensed. If licensed, I agree that

the place of business may be inspected and searched, during business hours or at any time business is being conducted on the

premises, by officials and agents of the Department of Revenue for the purposes of determining compliance with Chapter 206, F.S.

Sworn to (or affirmed) and subscribed before me

this ____________ day of ___________________ , ____________ .

State of _____________ County of ________________________________

__________________________________________

_________________________________________________________

Signature of Notary Public

Signature of Applicant

_________________________________________________________

Print or Type Applicant’s Name

__________________________________________

W A R N I N G :

Print, Type or Stamp Name of Notary

Personally Known __________ or Produced Identification __________

Read carefully: This instrument is a sworn document. False answers

Type of Identification Produced ___________________________________

could result in criminal prosecution subject to fine and/or imprisonment

and denial of your application.

Form Dr-156 - Florida Fuel Or Pollutants Tax Application Page 10