Form Dr-248 - Alternative Fuel Use Permit Application, Renewal, And Decal Order Form - 2013

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DR-248
DR-248
Alternative Fuel Use Permit
Alternative Fuel Use Permit
R. 11/12
R. 11/12
Application, Renewal, and Decal Order Form
Application, Renewal, and Decal Order Form
Rule 12B-5.150
Rule 12B-5.150
Florida Administrative Code
Florida Administrative Code
For Calendar Year _____
2013
Effective Date: 01/13
Effective Date: 01/13
Permit Number:
Permit Number:
For Period Ending:
For Period Ending:
FEIN or Social Security Number:
FEIN or Social Security Number:
Enter owner name, location address, and mailing address.
Enter owner name, location address, and mailing address.
Computation of Decal Fee(s)
Computation of Decal Fee(s)
Name of
Name of
Class A
Class A
Class B
Class B
Class C
Class C
Class A + B + C
Class A + B + C
county in
county in
which the
which the
vehicle is
vehicle is
Total
Total
Annual
Annual
= Class Total
= Class Total
= Class Total
= Class Total
= Class Total
= Class Total
x Number
x Number
x Number
x Number
x Number
x Number
Rate
Rate
Rate
Rate
Rate
Rate
predominately
predominately
Vehicles
Vehicles
Fees
Fees
of Vehicles
of Vehicles
of Vehicles
of Vehicles
of Vehicles
of Vehicles
used
used
271.50
271.50
271.50
380.10
380.10
380.10
199.10
199.10
199.10
199.10
199.10
199.10
271.50
271.50
271.50
380.10
380.10
380.10
199.10
199.10
199.10
271.50
271.50
271.50
380.10
380.10
380.10
199.10
199.10
199.10
271.50
271.50
271.50
380.10
380.10
380.10
199.10
199.10
199.10
271.50
271.50
271.50
380.10
380.10
380.10
271.50
271.50
271.50
380.10
380.10
380.10
199.10
199.10
199.10
199.10
199.10
199.10
271.50
271.50
271.50
380.10
380.10
380.10
199.10
199.10
199.10
271.50
271.50
271.50
380.10
380.10
380.10
Total
Total
+
+
=
=
+
+ +
Decals
Decals
Annual
Annual
$
$
$
$
$
$
+
+
=
=
+
+
Fees
Fees
x
x
Proration Factor
Proration Factor
(see Lines 9 and 10 of instructions)
(see Lines 9 and 10 of instructions)
$
$
Total Fees Due
Total Fees Due
Print or type applicant’s name _____________________________________________________
Print or type applicant’s name _____________________________________________________
Title ____________________________________Contact phone number ___________________________
Title ____________________________________Contact phone number ___________________________
Under penalty of perjury, I declare that I have read this application and the facts stated in it are true.
Under penalty of perjury, I declare that I have read this application and the facts stated in it are true.
Signature of applicant ____________________________________________________________________
Signature of applicant ____________________________________________________________________
Note: Social security numbers (SSNs) are used by the Florida Department of Revenue as unique identifiers for the administration of Florida’s taxes. SSNs
Note: Social security numbers (SSNs) are used by the Florida Department of Revenue as unique identifiers for the administration of Florida’s taxes. SSNs
obtained for tax administration purposes are confidential under sections 213.053 and 119.071, Florida Statutes, and not subject to disclosure as public records.
obtained for tax administration purposes are confidential under sections 213.053 and 119.071, Florida Statutes, and not subject to disclosure as public records.
Collection of your SSN is authorized under state and federal law. Visit our Internet site at and select “Privacy Notice” for more
Collection of your SSN is authorized under state and federal law. Visit our Internet site at and select “Privacy Notice” for more
information regarding the state and federal law governing the collection, use, or release of SSNs, including authorized exceptions.
information regarding the state and federal law governing the collection, use, or release of SSNs, including authorized exceptions.

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