Free DR-157B - Florida

MAIL TO: CENTRAL REGISTRATION - FUEL UNIT FLORIDA DEPARTMENT OF REVENUE PO BOX 6480 TALLAHASSEE, FL 32314 - 6480

Fuel Tax Cash Bond

DR-157B R. 08/03

Please complete and submit a separate bond form for each fuel product type or taxable pollutant. Importers must provide a separate bond form as surety for the required "Importer's Additional Bond". An applicant cannot be issued a fuel license by the Department of Revenue until the proper surety is submitted. If further information is needed, please contact Central Registration at 850-488-4772.



Motor Fuel License No. __________________________________ Diesel Fuel License No. __________________________________ Aviation Fuel License No. _________________________________ Pollutant Tax License No. _________________________________ Importer's License No. ___________________________________ Wholesaler of Alternative Fuel License No. ________________________________ Amount $ _____________________________

This is a cash bond or deposit made by the person or firm shown below to secure and guarantee payment of: ( ( ( ) Motor Fuel pursuant to Chapter 206, Florida Statues ) Diesel Fuel pursuant to Chapter 206, F.S. ) Aviation Fuel pursuant to Chapter 206, F.S. ( ( ( ) Pollutant Tax pursuant to Chapter 206, F.S. ) Importer's Additional Bond pursuant to section 206.051, F.S. ) Alternative Fuel pursuant to Chapter 206, F.S.

From: ___________________________________________________________________________________________
Name of Owner

_______________________________________________________________________________________________
Trade Name

Address: ________________________________________________________________________________________
(Street Adress)

_______________________________________________________________________________________________
(City) (County) (State) (ZIP)

For DOR Use Only
Accepted this ______ day of ______________ , _____ .
(month) (year)

Money Order No. ______________________________ Cashier's Check No. ___________________________ Certified Check No. ____________________________

Florida Department of Revenue
By __________________________________________
Name

NOTE: The original bond will be maintained by the Florida Department of Revenue.

____________________________________________
Title

Account Number: ______________________________