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Form Dr-248 - Alternative Fuel Use Permit Application, Renewal, And Decal Order Form - 2011

DR-248

2011 Alternative Fuel Use Permit

R. 11/10

Application, Renewal, and Decal Order Form

Rule 12B-5.150

Florida Administrative Code

Effective 01/11

Permit Number:

For Period Ending:

FEIN or Social Security Number:

Enter owner name, location address, and mailing address.

Computation of 2011 Decal Fee(s)

Name of

Class A

Class B

Class C

Class A + B + C

county in

which the

vehicle is

Rate

x Number

= Class Total

Rate

x Number

= Class Total

Rate

x Number

= Class Total

Total

Annual

predominately

of Vehicles

Vehicles

Fees

used

195.80

267.00

373.80

195.80

267.00

373.80

195.80

267.00

373.80

267.00

373.80

195.80

267.00

373.80

195.80

267.00

373.80

195.80

267.00

373.80

195.80

267.00

373.80

Total

Decals

Annual

Fees

Proration Factor

(see Lines 9 and 10 of instructions)

Total Fees Due

Print or type applicant’s name _____________________________________________________

Title ____________________________________Contact phone number ___________________________

I certify that this application has been examined by me and to the best of my knowledge and belief is true and complete.

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

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

information regarding the state and federal law governing the collection, use, or release of SSNs, including authorized exceptions.