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v <br /> s �.b <br /> DR-700218 <br /> R . 01 /10 <br /> Page 3 <br /> 1 certify that all the information is accurate and true to the best of my knowledge . I further certify that I will <br /> promptly report <br /> 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 right <br /> 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 /> Yes ONo <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 assignments or trusts entered into which obligated funds received from revenue sharing . <br /> Signed : Date 1 <br /> Chief Fiscal Officer <br /> Signed : • Date 04 / 06 / 10 <br /> Mayor or Cha. irmdn of Governi ody <br /> Peter . n- . O '-Brjan , Chairman <br /> r. RNMail' c.ompleted original application to address shown below : <br /> -Th Department of Revenue <br /> wy a • a 0 r n • . . : h \ <br /> Revenue Accounting Subprocess <br /> P . O . Box 6609 <br /> Tallahassee , FL 32314 - 6609 <br /> revenueaccounting@dor. state . fl. us <br />