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DR -700218 <br />R. 03199 <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 that I <br />will promptly report to the Department of Revenue any changes in the above information. I also realize that failure to <br />provide tim0 information required, pursuant to the administration of this Act shall, by such action, authorize the <br />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 />Yes © No F7 <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: . <br />—y 1� <br />(Chief ,Eisca Officer) <br />SignedINNETH <br />'`� <br />15Gov�en <br />��tjiyor or Chairmaody) <br />R. MACHT CHAIRMAM <br />Date: �R — <br />Date: s•' / 4 <br />Mail completed original application to address shown below. <br />Department of Revenue <br />Revenue Accounting Section <br />P.O. Box 6609 <br />Tallahassee, Florida 32399-6609 <br />