Local Business Tax Affidavit

DECLARATION OF TAXABLE VALUES
For a business that makes wholesale or retail sales (stores), provide the cost value of INVENTORY, excluding alcoholic beverages, tobacco products, and gasoline, as of the opening date of the business.
For restaurants, hotels, motels, apartments, provide the number of licensed accommodations (seats, rooms, apartments).
For businesses that have licensed professionals (e.g., attorneys, barbers, doctors, etc.), provide the name(s) and license type for each EMPLOYEE and OWNER. Do not include independent contractors.
For vending machine, self-serve laundry machines, amusement machines, etc., provide the type and number of each machine.
For service businesses such as lawn services, janitorial services, auto repair, bakeries, auto detailing, etc., provide the number of workers, including the owner(s).
For transportation businesses such as taxis, vehicle rentals, and other vehicles-for-hire, provide the number of vehicles in the fleet.
For gas stations, provide the number of nozzles that can operate simultaneously. For example, if an island has a nozzle on both sides, count is as two (2) nozzles.
Name of person submitting this form.*

First NameLast Name
Title of person submitting this form.*
Date submitted*

MonthDayYear
Date

FICTITIOUS NAME INFORMATION

Florida Fictitious Name Act
This business is a currently registered corporate entity with the Florida Division of Corporations that ONLY uses the corporate name to conduct business (no fictitious name/dba).The business name is the owner's personal legal name (ex.: John Doe)The business is licensed by the Florida Department of Business & Professional Regulation (DBPR), the Florida Department of Health, or is a law office with attorneys admitted to the Florida BarThe business is a federally chartered corporation (ex.: National Association)This business uses a fictitious name/dba that has been registered with the Florida Division of Corporations (sunbiz.org).
Upload a copy of the corporate registration and/or the fictitious name/dba registration from the Division of Corporations (sunbiz.org). NOTE: If the document says "Application", it can't be accepted.

Cancelof
Date submitted*

MonthDayYear
Date

FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN)

SOCIAL SECURITY NUMBER (SSN)
F.S. §205.0535(6) requires all businesses to provide the FEIN or owner's social security number.

A receipt may not be issued unless the federal employer identification number or social security number is obtained from the person to be taxed.
FEIN (see next field)Owner's SSN (do not provide)
Provide the FEIN. Do not provide any person's SSN for protection of personally identifiable information.
Please verify that you are human*
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Local Business Tax Information