Form Dr-5 - Application For Consumer'S Certificate Of Exemption 2003
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1DR-5
Application for Consumer’s Certificate of Exemption
R. 02/03
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:
CENTRAL REGISTRATION
FLORIDA DEPARTMENT OF REVENUE
5050 W TENNESSEE ST
TALLAHASSEE FL 32399-0100
Exemption category for which you are applying (check only one):
501 (c)(3) Organization
Library Cooperative
Religious - physical place of
Filing Tips
worship
Community Cemetery
Nonprofit Cooperative Hospital
•
Use blue or black ink only.
Religious - governing/
Laundry
Credit Union
administrative
•
Do not staple application or
Nonprofit Water System
Fair Association
Religious - transportation
supporting documents.
Organization Benefiting Minors
Florida Fire and Emergency
provider
•
Please limit size of supporting
Parent-Teacher Organization/
Services Foundation
School, College or University
Association
documents to 8 1/2" x 11"
Florida Retired Educators
Veterans’ Organization
(letter size). Larger
Political Subdivision
Association
documents will delay the
Volunteer Fire Department
processing of your application.
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