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DR-700218 <br /> R. 04/08 <br /> Page 3 <br /> 1 certify that all information is accurate and true to the best of my knowledge. I further certify that I will promptly <br /> report to the Department of Revenue any changes in the above information . I also realize that failure to provide timely <br /> information required , allows the Department to utilize the best information available. If no such information is available, <br /> the Department will take necessary action including disqualification , either partial or entire, and you will waive your <br /> right to challenge the determination of the Department to your share of funds, if any, beyond your minimum entitlement, <br /> according to 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 listed above? <br /> OYes O No <br /> If the answer to question above is (NO) , please provide an attachment of the revenue necessary to meet your obligations <br /> because of pledges or. apsiiggnments or trusts entered into which obligated funds received from revenue sharing . <br /> Signed : ^ Date: 05/14/2008 <br /> Chief Fiscal Official <br /> Signed Adt4 Date: �• Q� <br /> Mayor or Chairman of Governing Body <br /> IVlail completed 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 />