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DR-700218 <br /> R . 05/03 <br /> Page 4 <br /> Part Three <br /> hereby certify that all of the foregoing information is accurate and true to the best of my knowledge . I further certify <br /> 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 timely 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 /> XF;-777 <br /> Yes No <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: \ Date : a� ) <br /> C ' f Fiscal Official <br /> Signed : Date : 06 / 03 / 03 <br /> Kenneth R . T? Cc ?fCh�jsmalrman erring Body <br /> Mail completed original application to address shown below. <br /> DEPARTMENT OF REVENUE <br /> REVENUE ACCOUNTING SUBPROCESS <br /> PO BOX 6609 <br /> TALLAHASSEE FL 32399-6609 <br />