DR-841 
                                                                                                                           R. 07/15 
                                                                                                                                  TC 
                                                                                                                           Rule 12-22.005 
                                         Request for Copy of Tax Return                                                    Florida Administrative Code 
                                                                                                                           Effective 07/15 
                                                                                                                                   
               This form is used to request a copy of any tax return filed with the Florida Department of Revenue.

Section 1: Taxpayer Information
Taxpayer Name:

Florida Tax Registration Number:             Federal Employers Identification Number (FEIN): Social Security Number (SSN)*:

Street or Mailing Address:

City:                                        State:                                          ZIP:

Email Address:                               Telephone Number:                               Fax Number:

Section 2: Taxpayer Representative - This section is to be completed when a taxpayer representative will be receiving the records 
requested. A signed Power of Attorney and Declaration of Representative (Form DR-835) must be attached.
Representative Name:

Street or Mailing Address:

City:                                        State:                                          ZIP:

Email Address:                               Telephone Number:                               Fax Number:

Section 3: Return(s) Requested
Tax Return Type: (select all that apply)
      Amusement Machine Certificate Fee                        From:                                    To:
      Communications Services Tax                              From:                                    To:
      Corporate Income Tax                                     From:                                    To:
      Documentary Stamp Tax                                    From:                                    To:
      Estate Tax                                               Date of Death:                           Decedent's SSN*:
      Florida Business Tax Application                         From:                                    To:
      Fuel Tax                                                 From:                                    To:
      Government Leasehold (Intangible) Tax                    From:                                    To:
      Gross Receipts Tax on Dry Cleaning                       From:                                    To:
      Gross Receipts Tax on Utility Services                   From:                                    To:
      Insurance Premium Taxes and Fees                         From:                                    To:
      Miami-Dade Lake Belt Mitigation Fees                     From:                                    To:
      Motor Vehicle Warranty Fee                               From:                                    To:
      Oil Production Tax                                       From:                                    To:
      Pollutants Tax                                           From:                                    To:
      Reemployment Tax (formerly Unemployment Tax)             From:                                    To:
      Rental Car Surcharge                                     From:                                    To:
      Sales and Use Tax                                        From:                                    To:
      Solid Minerals Severance Tax                             From:                                    To:
      Solid Waste Fees (Tires/Batteries)                       From:                                    To:
Additional Information on Return(s) Requested:

Section 4: Delivery - Indicate whether the tax return(s) is to be delivered to the taxpayer or to the taxpayer's representative. Select only one method             DR-841 
                                                                                                                                                                    R. 07/15 
of delivery. If you select email, select whether to receive the email using a secure email system or through an unsecure email system.                              Page 2
Recipient of Tax Return(s):                 Method to Provide Tax Return(s):

  I authorize the Department to send the requested tax return(s) using the Florida Department of Revenue's secure email.  I understand that this method 
  requires additional steps to view the tax return(s) provided.
  I authorize the Department to send the requested tax return(s) using an unsecure email to the address indicated.  I acknowledge that the tax return(s) 
  may be viewed by someone other than the taxpayer or taxpayer representative indicated.

Authorization and Signature
  I authorize the release and delivery, as indicated in this request, of the confidential information contained in the above-described tax return(s).

Taxpayer Signature                                                                      Date
OR

Representative Signature                                                                Date
*Social security numbers (SSNs) are used by the Florida Department of Revenue as unique identifiers for the administration of Florida's taxes. SSNs obtained for tax administration purposes are confidential under 
sections 213.053 and 119.071, Florida Statutes, and not subject to disclosure as public records. Collection of your SSN is authorized under state and federal law. Visit our Internet site at www.floridarevenue.com and 
select "Privacy Notice" for more information regarding the state and federal law governing the collection, use, or release of SSNs, including authorized exceptions.

                                        Request for Copy of Tax Return Instructions 
                                                                      
                   This form is used to request a copy of any tax return filed with the Florida Department of Revenue. 
                                                                      
General Instructions 
Your privacy is important to the Department.  To protect your privacy, access to personal information about you is limited to individuals 
authorized by law to have access to that information.  To ensure that information is not provided without your consent, a written request from 
you is required before the Department will provide tax returns to anyone.  
  
Section 1 - Taxpayer Information 
To protect the privacy of your business information, the information entered in this section must be the same as the taxpayer information 
maintained by the Department. 
  
Section 2 - Taxpayer Representative 
Complete this section only if the tax return(s) requested will be provided to an authorized representative.  You must attach a completed and 
signed Form DR-835, Power of Attorney and Declaration of Representative, authorizing the representative to receive the tax return(s).  
  
Section 3 - Return(s) Requested 
Indicate the tax return(s) and the filing period(s) that you need.  
  
Section 4 - Delivery  
Indicate the method by which you wish to receive the tax return(s) - email, fax, or mail. If you indicate email, unless you authorize the 
Department to send your tax return(s) using an unsecure email, the Department will send the requested return(s) using its secure email 
software.  This software will require additional steps before you can access your return(s).  If you choose to receive the tax return(s) by 
unsecure email, they will be sent to the email address that you provided.  Remember that unsecure emails may be accessed or viewed by 
someone other than the intended recipient.  
  
Authorization/Signature 
You must sign this request if you are the taxpayer requesting the tax return(s) or if you are authorized by the taxpayer to receive the taxpayer's 
tax return(s).  The Department cannot process your request without your signature or without you authorizing the release of the tax 
information contained in the requested tax return(s). 
  
Fax or mail this request to the address below.  If the requested return(s) will be delivered to an authorized representative, include a 
completed and signed Power of Attorney. 
  
                                            Records Management, MS 1-5730 
                                            Florida Department of Revenue 
                                                      5050 W. Tennessee Street 
                                                      Tallahassee FL 32399-0158 
                                                                      
                                            Fax: 850-922-5936 or 850-922-0861 
  
                         If you have questions or need assistance completing this form, call us at 850-488-6800.