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DR-700218 <br /> R. 04/09 <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 <br /> promptly <br /> report to the Department of Revenue any changes in the above information . I also realize that failure to <br /> provide timely <br /> information required , allows the Department to utilize the best information available . If no such information is <br /> 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 <br /> obligations <br /> because of pledges or assignments or trusts entered into which obligated funds received from revenue sharing . <br /> 1� Date : 05/ 18/2009 <br /> Signed : _ <br /> Chief Fiscal Official — _-- <br /> Signed : ""e�- Date : June 2 , 2009 <br /> ayor or Chairman of Governing Body — — — <br /> 1,sley S . Davis , _ Halrman <br /> (Mail 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 /> revenueaccounting@dor. state .fl . us <br />