Form Dr-17a - Florida Sales And Use Tax Certificate Of Cash Deposit/cash Bond

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DR-17A
Florida Sales and Use Tax
R. 03/10
Certificate of Cash Deposit/Cash Bond
Rule 12A-1.097
Florida Administrative Code
Effective 06/10
Business Partner/Certificate Holder
Certificate Number
Federal Employer Identification Number
Business Location Street Address
City
County
State
ZIP Code
Mailing Address
City
County
State
ZIP Code
I am filing with the Florida Department of Revenue this Certificate of Deposit/Cash Bond and the attached CASHIER’S
CHECK or MONEY ORDER in the amount of:
______________________________________________________________________________________ ($ ________________ ).
The Business Partner/Certificate Holder offers or plans to offer services and/or products subject to sales tax,
discretionary sales surtax, fees, or surcharges imposed by or administered by the Department of Revenue according
to Chapter 212, Florida Statutes (F.S.), and is required to provide the Department with security, conditioned upon
compliance with the requirements of Chapter 212, F.S.
The Business Partner/Certificate Holder agrees:
1. To collect and remit applicable taxes, surtaxes, fees, and surcharges in a timely manner in accordance with the
requirements of Chapter 212, F.S.
2. If the Business Partner/Certificate Holder is more than 30 days delinquent in the payment of any applicable tax,
surtax, fee, surcharge, interest or penalty the Department may cancel this Certificate of Cash Deposit/Cash Bond
and apply the deposited amount to any unpaid liabilities. Should this occur, I understand that a new certificate/bond
may be required.
Under penalties of perjury, I declare that I have read the foregoing certificate and that the facts stated in it are true.
________________________________________________________________________
___________________________
Signature of Owner(s), Partner, Corporate Officer, or Member
Date
Accepted for the Department of Revenue by:
________________________________________________________________________
___________________________
Signature of Executive Director or Designee
Date

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