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DR-700218 <br /> R. 04/07 <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 /> AI Yes I 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:(;, � o'`� Date: S Z3 O <br /> . . , oghief Fiscal Official <br /> Signed : Date: June 5 , 2007 <br /> Mayor or Chairman of Governing Body <br /> I <br /> I, •` Mail .cgmpieted original application to address shown below. <br /> Florida Department of Revenue <br /> Revenue Accounting Subprocess <br /> PO Box 6609 <br /> Tallahassee FL 32399-6609 <br />