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DR400218 <br /> R. 03/12 <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 /> Yes No <br /> Z ❑ <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 /> .MM <br /> Signe : e ;!*v <br /> ° MMISsj"' " •,. Date : <br /> Chief Fiscal Official ,.J�� • •.;9�'• <br /> j <br /> : U ; ' <br /> i <br /> .� _a_..__ y ' • <br /> Signed : • te : 05 /� 1 / 12� <br /> Mayor or Chairman of Governing B0£%44/'q o mma CIN <br /> `o '0•0 <br /> Gary C . Wheeler <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 32314-6609 <br /> 850 =617 =8586 <br /> REVENUEACCOUNTING@dor. state . fl . us <br />