Form Dr-156 - Florida Fuel Or Pollutants Tax Application Page 19

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DR-157B
MAIL TO:
FLORIDA DEPARTMENT OF REVENUE
R. 10/13
Fuel or Pollutants Tax Cash Bond
ACCOUNT MANAGEMENT - FUEL UNIT
TC
MS 1-5730
5050 W TENNESSEE ST
Rule 12B-5.150
Florida Administrative Code
TALLAHASSEE, FL 32399- 0160
Effective 01/14
Please complete and submit a separate bond form for each fuel product type or taxable pollutant. Importers must
provide a separate bond form as surety for the required “Importer’s Additional Bond”. An applicant cannot be issued a
fuel license by the Department of Revenue until the proper surety is submitted. If further information is needed, please
contact Account Management - Fuel Unit at 850-488-6800.
❑
Motor Fuel License No. ______________________________________
❑
Diesel Fuel License No. ______________________________________
❑
Aviation Fuel License No. ____________________________________
❑
Pollutant Tax License No. ____________________________________
❑
Importer’s License No. _______________________________________
❑
Wholesaler of Alternative Fuel License No. ____________________________________
Amount $ _________________________________
This is a cash bond or deposit made by the person or firm shown below to secure and guarantee payment of:
(
) Motor Fuel pursuant to Chapter 206, Florida Statues (
) Pollutant Tax pursuant to Chapter 206, F.S.
(
) Diesel Fuel pursuant to Chapter 206, F.S.
(
) Importer’s Additional Bond pursuant to section 206.051, F.S.
(
) Aviation Fuel pursuant to Chapter 206, F.S.
(
) Alternative Fuel pursuant to Chapter 206, F.S.
From: _____________________________________________________________________________________________________
Name of Owner
___________________________________________________________________________________________________________
Trade Name
Address: ___________________________________________________________________________________________________
(Street Address)
___________________________________________________________________________________________________________
(City)
(County)
(State)
(ZIP)
Money Order No.__________________________________
For DOR Use Only
Cashier’s Check No. _______________________________
Accepted this ______ day of ________________, ______ .
Certified Check No. _______________________________
(month)
(year)
Florida Department of Revenue
By _______________________________________________
NOTE: The original bond will be maintained by the
Name
Florida Department of Revenue.
__________________________________________________
Title
Account Number: __________________________________

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