Free DR-55 - Florida

Application for Compensation for Tax Information

DR-55 R. 03/09
Rule 12-18.004 Florida Administrative Code Effective 06/09

DOR Control Number

Statement of Eligibility
I certify that: · · I am 18 years of age or older and am applying for compensation in accordance with section 213.30, Florida Statutes, and Chapter 12-18, Florida Administrative Code. I, as an individual, as an officer of a corporation, or as a partner in a partnership, did not come into possession of information relating to a tax violation while employed with the Florida Department of Revenue or as an employee of any other state or federal agency. The Department will accept such information; however, no compensation will be paid if monies are collected as a result of information collected from someone employed with the Florida Department of Revenue or as an employee of any other state or federal agency. I understand that no information regarding the case may be disclosed to me, except the amounts of any monies collected as a result of my information. I understand that the referenced taxpayer has the right to obtain information from the Florida Department of Revenue that identifies me.

· ·
Mr. Mrs. Ms.

_______________________________________________________________________ Name of Applicant _______________________________________________________________________ Mailing Address

______________________________ FEIN or Social Security Number ______________________________ Phone Number

___________________________________________________________________________________________________________ City County State ZIP Under penalties of perjury, I declare that I have read the foregoing Statement of Eligibility and that the facts stated in it are true. ___________________________________________________________________________________________________________ Signature of Applicant Title Date

Notice
Social Security Numbers are required by the Florida Department of Financial Services for check issuance and used by the Florida Department of Revenue as unique identifiers for the administration of Florida's taxes. Social Security Numbers obtained for tax administration purposes are confidential under sections 213.053 and 119.071, Florida Statutes, and not subject to disclosure as public records.

DR-55 R. 03/09 Page 2

Section 213.30, Florida Statutes, authorizes the Executive Director of the Department of Revenue to compensate persons who provide information leading to the registration of a noncompliant taxpayer and/or collection of taxes, penalties, and interest with respect to the following taxes: · · · · · · · · · · · · · · · · · · Communications services tax Corporate income and emergency excise tax Estate tax Documentary stamp tax Fuel taxes on motor fuel, diesel fuel, aviation fuel, and alternative fuel, including local option taxes Government leasehold intangible personal property tax Gross receipts tax on dry-cleaning Gross receipts tax on natural gas, manufactured gas, or electricity Insurance premium taxes, fees, regulatory assessments, excise taxes, and surcharges required to be remitted to the Department Intangible personal property tax Local option convention development tax, tourist development tax, and tourist impact tax when the imposing local government has not elected to self-administer the tax Miami-Dade County lake belt mitigation and water treatment plant upgrade fees Motor vehicle warranty fees Pollutant taxes Rental car surcharge Sales and use tax and local option discretionary sales surtaxes Severance taxes, fees, and surcharges on gas and sulfur production, oil production, and solid mineral severance; and Solid waste fees, including the new tire fee and the new or remanufactured lead-acid battery fee

The receipt of this information places the Department under no obligation to pursue the case based on this information. The Department will determine whether an investigation or audit is a wise use of the public funds under the particular circumstances. For general tax information, call Taxpayer Services, Monday-Friday, 8:00 a.m. to 7 p.m., ET, at 800-352-3671. Persons with hearing or speech impairments may call our TDD at 800-367-8331 or 850-922-1115. Send this completed application to: Florida Department of Revenue General Tax Administration Compensation for Tax Information PO Box 6417 Tallahassee FL 32314-6417 For questions relating to the Compensation for Tax Information Program, call 800-FL-AWARD (800-352-9273 in Florida only) or 850-487-9987.

Noncompliant Taxpayer Information
Please complete the following information about the noncompliant taxpayer you are reporting.

DR-55 R. 03/09 Page 3

Business Information
Name of Taxpayer Who Committed Tax Violation ______________________________________________________________ Doing Business As (D/B/A) __________________________________________________________________________________ Business Location _________________________________________________________________________________________ City _____________________________________County _________________ State ______________ ZIP _________________ Mailing Address (if different) _________________________________________________________________________________ City _____________________________________County _________________ State ______________ ZIP _________________ How Long in Business_____________________________Date or Period of Violation _________________________________ Type of Tax ______________________________________Type of Business ________________________________________ FEIN ____________________________________________SSN ____________________________________________________ Sales and Use Tax Certificate Number ________________________________________________________________________

Banking Information
Business Bank Name ______________________________________________________________________________________ Bank Address _____________________________________________________________________________________________ City _____________________________________County _________________ State ______________ ZIP _________________ Primary Business Account Number _____________________________________________________

Description
Summary of Violation (attach additional pages if necessary) _____________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________