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H <br /> D R-70021 FA <br /> R. 04/06 <br /> Page •4 <br /> Part Three <br /> I hereby certify that all of the foregoing information is accurate and true to the best of my knowledge . I further certify <br /> that I will promptly report to the Department of Revenue any changes in the above information . I also realize that <br /> failure to provide timely information required , pursuant to the administration of this Act shall, by such action , authorize <br /> the Department to utilize the best information available or, if no such information is available, to take necessary action <br /> including DISQUALIFICATION , EITHER PARTIAL OR ENTIRE , and shall further, by such action , waive any right to <br /> challenge the determination of the Department to its share of funds , if any, beyond its minimum entitlement, pursuant to <br /> the privilege of receiving shared revenues from the Revenue Sharing Trust Funds . <br /> Do you believe that you have complied with ALL eligibility requirements as set forth above ? <br /> E] Yes F-1 No <br /> If the answer to the above question is (NO), please provide as an attachment to this form the amount of revenue <br /> necessary to meet your obligations as a result of pledges or assignments or trusts entered into which obligated funds <br /> received from revenue sharing . <br /> Signed : Date : <br /> Chief Fiscal Official <br /> Signed : ' Date : June 6 , 2006 <br /> Ma of hairman of Gov rnin Body <br /> Artvhur t 2 i�.' uber•,ge � , Chairman <br /> "Mail completed original application to address shown below. <br /> FLORIDA DEPARTMENT OF REVENUE <br /> ,> >`" '.. r ..•' , REVENUE ACCOUNTING SUBPROCESS <br /> PO BOX 6609 ' <br /> TALLAHASSEE FL 32399-6609 <br />