DR-843
                             Purchaser’s Application for  
                                                                                                  R. 12/15
                             Transferee Liability Certificate

___________________________ has purchased or is purchasing a business or stock of goods from:

                             _____________________________________
                                  (Name of Selling Dealer)
 
                             __________________________________________________
                                  Address
 
                             __________________________________________________
                                  City, State, ZIP 

                             __________________________________________________
                                  Business Partner Number
 
The purchaser is requesting a Transferee Liability Certificate for the period  ___________________  
through  ___________________ .

Purchaser’s signature:  ________________________  Telephone Number:  __________________

Please attach documentation to this form to verify the sale or proposed sale of the business. 

NOTE - The Department will only deliver the certificate to the seller of the business, unless the 
Department asserts transferee liability against you or other responsible person(s), based on the 
contents of the certificate.

When complete, mail the form to:  General Tax Administration Program
                                  Compliance Standards
                                  PO Box 5139
                                  Tallahassee, FL  32314-5139 
                                  Phone: 850-617-8565
                                  Fax: 850-921-6174