APPLICATION FOR BUSINESS TAX RECIPT

I, First name* Last Name* , hereby certify that I am exempt from payment of a County Business Tax based on the following:

(REQUIRED) Make one selection below:

• Per Florida Statute §205.055 I own a majority interest in a business with fewer than 100 employees. The business or occupation for which I desire a Business Tax Receipt is fully described on the attached application form and that such business or occupation is carried on mainly through my personal efforts as a means of livelihood. I am:*

A veteran of the United States Armed Forces who was honorably discharged upon separation from service, or the spouse or un-remarried surviving spouse of such a veteran, as verified by providing one of the following: -DD Form 214, Certificate of Release or Discharge from Active Duty, issued by the United States Department of Defense OR -US DoD Uniformed Services Retired Identification and Privilege Card or Veterans Identification Card, issued by the United States Department of Veterans Affairs pursuant to the Veterans Identification Card Act of 2015, Pub. L 114-31 OR -Valid Florida Driver License or Florida Identification Card with the “Veteran” designationThe spouse of an active duty military service member who has relocated to the county or municipality pursuant to a permanent change of station order, as verified by providing: -Military Permanent Change of Station (PCS) ordersA person who is receiving public assistance as defined in Florida Statute §409.2554, as verified by providing: -Proof of enrollment in the Department of Children and Families’ Access Florida Benefits Program.(Access cards must have valid dates shown) OR -Proof of enrollment in Medicaid (must have valid dates shown)A person whose household income is below 130% of the federal poverty level based on the current year’s federal poverty guidelines, as verified by providing: -Tax return from last tax year

Per Florida Statute §205.065 I am:*

Regulated by the state Department of Business and Professional Regulation and have paid a business tax for the current year to the county or municipality in the state where my permanent business location or branch office is maintained, as verified by providing: -Copy of BTR from county or municipality of permanent business location and -Copy of license / registration from DBPR

Per Florida Statute §205.162 I have no more than one employee or helper and use my own capital, not in excess of$1,000. I am:*

A disabled person physically incapable of manual labor, as verified by providing: -A certificate from a reputable physician indicating that the applicant is disabled, including the nature and extent of the disability.A widow(er) with minor dependents, as verified by providing: -Proof of the right to the exemptionA person aged 65 years or older, as verified by providing: -Valid State issued License or Identification Card

None of the above apply*

None of the above apply

(REQUIRED) Please upload supporting documents

Prior to requesting a renewal of said Business Tax Receipt, I will notify the Tax Collector should I no longer qualify for the exemption.

UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT ALL THE FACTS IN IT ARE TRUE AND CORRECT

Signature of Applicant*

Date*

Date

APPLICATION FOR BUSINESS TAX RECEIPT

Business Information

Owner Information

License Information (If Applicable)

REQUEST FOR FEE EXEMPTION