DR-342000
Yes
No
R. 01/16
Page 5
N
Y
Does the entity buy fuel in bulk quantities for his/her own use? If yes, what types of fuel?
q
q
q
q
Check all that apply.
Gasoline
Undyed Diesel
Dyed Diesel
Other_________________
23g. Reemployment Tax (Section 443.1215, F.S., Chapter 73B-10, F.A.C., Form RT-6):
Yes
No
Y
N
Is your entity incorporated?
N
Y
Do you have any employees?
Y
N
Have you paid $1,500 in wages in a calendar quarter?
N
Have you employed 1 or more persons for any portion of a day in 20 different weeks during the
Y
calendar year?
N
Y
Are you liable for Federal Unemployment Tax (FUTA) because of employment in another state for the
current or proceeding year?
N
Y
Are any corporate officers performing services?
N
Y
Are dividends paid to an employee of a subchapter S Corporation?
N
Y
Are you a governmental entity?
N
Y
Are you a nonprofit who has a 501(c)(3) exemption and have 4 or more workers for 20 different weeks in a calendar year?
N
Y
Are you an agricultural employer who has paid cash wages of $10,000 or more in a calendar quarter or has had five
or more employees for 20 different weeks in a calendar year?
Y
N
Have you acquired a business that was liable for reemployment tax?
24. Attach a list of any outstanding liens, warrants, or Notices of Tax Action filed against the taxpayer for any tax type by the
Florida Department of Revenue.
25. Attach a Power of Attorney (Form DR-835) for the qualified practitioner.
26. Attach a statement, signed by the taxpayer, declaring the taxpayer’s intent to pay any audit assessment within 60 days of the
date the audit has been agreed to, or the protest opportunities have expired.
Applicant Signature: (The application cannot be processed unless signed by the taxpayer and the qualified practitioner.)
I declare that I have read the foregoing application and the facts stated in it are true.
____________________________________________
__________________________________________
_________________________
Taxpayer Signature
Print Taxpayer Name and Title
Date
____________________________________________
__________________________________________
_________________________
Qualified Practitioner Signature
Print Qualified Practitioner Name and Title
Date
Please mail the completed application to the following address:
Program Manager
Florida Department of Revenue
Certified Audit
PO Box 5139
Tallahassee, FL 32314-5139
If the request is approved, the Department will provide the following:
•
A confirmation letter to the CPA firm
•
A DR-15 download (SUT filing history) for use in planning work
•
A 30-day window to submit Proposed Agreed Upon Procedures tailored to the client
•
An electronic copy of the Standard Audit Program
•
An electronic copy of the shell Proposed Agreed Upon Procedures
If you have any questions or need assistance in completing your application, please call the Certified Audit Program Office at (850) 617-8578.