DR-842
                                                                                               R. 12/15
                  Seller’s Application for Transferee 

                                  Liability Certificate

The dealer referenced below, has sold or is selling his or her business or stock of goods, and 
is applying for a Transferee Liability Certificate for the period  __________  through  ___________ .

Name of Selling Dealer:  ____________________________________________

Mailing Address:  __________________________________________________

City, State, ZIP:  ___________________________________________________

Business Partner Number:  ______________________

When the audit is complete, send the certificate to:

Name of Purchaser:  _______________________________________________

Mailing Address:  __________________________________________________

City, State, ZIP:  ___________________________________________________

I give the Department permission to include in the certificate, information about the requested audit 
which you may not, without permission, disclose without violating the confidentiality requirements of 
section 213.053, Florida Statutes.

Signature of Owner or Representative of Selling Dealer:

____________________________________________

Name of Owner or Representative:

____________________________________________
                 (Please print)
 
Telephone Number:

____________________________________________

Mail to:  General Tax Administration Program
 Compliance Standards
 PO Box 5139
 Tallahassee, FL  32314-5139
 Phone: 850-617-8565
 Fax: 850-921-6174