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AGENDA ITEM # 413
JUNE 11, 2012
Application for Revenue Sharing 2012 -2013 State Fiscal Year
(Chapter 218, Part II Florida Statutes)
Application deadline is June 30, 2012
Mail completed original application to:
Department of Revenue
Revenue Accounting Subprocess
P.O. Box 6609
Tallahassee, FL 32314 -6609
850 - 617 -8586
REVENUEACCOUNTING @dor.state.fl.us
Please TYPE or PRINT
Name of County
DR- 700218
R. 03112
OR
Name of Municipality l City of Atlantic Beach County DUVAL
Telephone Number (904) 247 -5807
Fax Telephone Number (904) 247 -5819
Mayor or Chairman of Governing Body IMayor Louis "Mike" Borno
Chief Fiscal Officer lNelson Van Liere, Finance Director
E -mail Address Invanlie re @coab.us
Official Mailing Address 000 Seminole Road, Atlantic Beach, FL 32233
❑ Check here if the address represents a change from the previous application.
Federal Employer I.D. Number I (required for new participants only).
Please complete the questions below to determine your eligibility to participate in Revenue Sharing for this fiscal
year.
1. Have you submitted your financial statements for fiscal year ending 09/30/10 to the Department of Financial Services
as required by s. 218.32, F.S.?
Yes
No
2. Have you made provisions for annual postaudits of your financial accounts as provided by
s. 11.45, F.S.?
Yes 1-1 No
2/25/2011
Date of Audit Report
9/30/2010
Fiscal Year -End
AGENDA ITEM # 4B
JUNE H, 2012 DR- 700218
R. 03112
Paae 2
Have you reported on your most recent financial statement revenues equivalent to three mills calculated based on
your 1973 taxable values? This revenue should be net of debt service or special millages approved by the voters.
The revenue can be generated by a combination of ad valorem tax, utility tax, occupational license tax, or a payment
from the county as allowed by s. 125.01, Florida Statutes.
Yes
F] No
If you have a law enforcement department, answer the questions below: (if you have a contracted or strictly
volunteer department, skip to question 5)
(A) Have your law enforcement officers, as defined by s. 943.1 0(l), F.S., met the qualifications for employment as
established by the Criminal Justice Standards and Training Commission, and do you compensate them at an
annual salary rate of six thousand dollars ($6,000) or more?
Yes
❑ No
(B) Does the salary structure and salary plans for law enforcement officers meet the requirements of
Chapter 943 F.S.?
ZYes
❑ No
If you have a fire department, answer the questions below: (If you have a contracted or strictly volunteer
department, skip to question 6)
(A) Have your firefighters, as defined by s. 633.30(1), F.S., met the requirements stated in s. 633.34, 633.35, and
633.382 F.S.
1-1 Yes 1-1 No
(B) Does your fire department employ any full -time firefighters, who currently have either a bachelor's degree or
associate degree from a college or university which is applicable to fire department duties, if the degree is not a
requirement for their current position?
❑ Yes
❑ No
(C) If so, are these firefighters currently receiving supplemental compensation for those degrees?
[]
102
6. Are dependent special districts budgeted separately from the general budget of your government? Do they meet the
provisions for annual postaudit of their financial accounts in as provided by s. 11.45(3), F.S.?
❑Yes ❑ No Does Not Apply
7. Have you met the requirements of s. 200.065, F.S., if applicable? (The annual certification must be within 30 days of
adoption of an ordinance or resolution establishing a final property tax levy or, if no property tax is levied, not later
than November 1.
Yes
No
The portion of revenue sharing funds which, according to Part Il, Chapter 218, F.S., would otherwise be distributed
to a unit of local government which has not certified compliance or has otherwise failed to meet the requirements
of s. 200.065, F.S., shall be deposited in the General Revenue Fund for the 12 months following a determination of
noncompliance by the department.)
AGENDA ITEM # 413
JUNE 11, 2012
DR- 700218
R. 03/12
Page 3
I certify that all information is accurate and true to the best of my knowledge. I further certify that I will promptly
report to the Department of Revenue any changes in the above information. I also realize that failure to provide timely
information required, allows the Department to utilize the best information available. If no such information is available,
the Department will take necessary action including disqualification, either partial or entire, and you will waive your
right to challenge the determination of the Department to your share of funds, if any, beyond your minimum entitlement,
according to the privilege of receiving shared revenues from the Revenue Sharing Trust Funds.
Do you believe that you have complied with ALL eligibility requirements as listed above?
Yes No
F]
If the answer to question above is (NO), please provide an attachment of the revenue necessary to meet your obligations
because of pledges or assignments or trusts entered into which obligated funds received from revenue sharing.
Signed:
' --z 54 � Date: 5/22/2012
Chief Fiscal Official
Signed:
Mayor or Chairman of Governing Body
Date:
Mail completed original application to address shown below.
Florida Department of Revenue
Revenue Accounting Subprocess
PO Box 6609
Tallahassee, FL 32314 -6609
850 - 617 -8586
REVENUEACCOUNTING @dor.state.fl.us