Form Dr-5 - Application For Consumer'S Certificate Of Exemption 2010
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1DR-5
Application for Consumer’s Certificate of Exemption
R. 11/10
Sales and Use Tax [pursuant to ss. 212.08(6), (7), and 213.12(2), Florida Statutes]
* NO FEE REQUIRED *
CHECK ONE:
New
Renewal
Certificate No. _______________________________
MAIL TO:
ACCOUNT MANAGEMENT/EXEMPTIONS
FLORIDA DEPARTMENT OF REVENUE
PO BOX 6480
TALLAHASSEE FL 32314-6480
Exemption category for which you are applying (check only one):
501 (c)(3) Organization
Nonprofit Cooperative Hospital
Religious - governing/
Office Use Only
Laundry
administrative
Community Cemetery
Nonprofit Water System
Religious - transportation
BP ___________________
Credit Union
provider
Organization Benefiting Minors
Fair Association
CO __________________
School, College or University
Parent-Teacher Organization/
Florida Fire and Emergency
Association
Veterans’ Organization
RS _________ N ___R __
Services Foundation
Political Subdivision
Volunteer Fire Department
Florida Retired Educators
PM Date _____________
Association
Religious - physical place of
worship
Library Cooperative
Date Rec'd ___________
Organization Name
Street Address
Business Phone
(
)
City/State/ZIP
County, if located in Florida
Does organization hold IRS exempt
Federal Employer Identification Number (FEIN)
Is Organization incorporated?
Date of Incorporation
status?
■
■
■
■
Yes
No
Yes
No
Mailing Address (If different than above)
Alternate Phone
(
)
City/State/ZIP
County, if located in Florida
■
■
Does the organization receive income from the sale or lease of tangible personal property, the lease of real property or the sale of taxable services? Yes
No
If yes, provide the organization’s sales and use tax certificate of registration number:
ALL DOCUMENTS SUBMITTED WILL BE RETAINED AS PART OF THIS APPLICATION.
CERTIFICATION
I hereby attest that I am authorized to sign on behalf of the applicant organization described above. I further attest that,
if granted, the Consumer’s Certificate of Exemption will only be used in the manner authorized for this organization under
ss. 212.08(6), (7), or 213.12(2), Florida Statutes.
I declare that I have read the information provided on this application, including the attached documentation, and that
the facts stated herein are true.
_____________________________________________
______________________________________________
Signature
Title
_____________________________________________
______________________________________________
Print name
Date
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Parent category: Financial