Fillable PALM BEACH COUNTY PUBLIC SERVICE TAX AFFIDAVIT OF (Clerk of the Circuit Court & Comptroller, Palm Beach County)

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PALM BEACH COUNTY PUBLIC SERVICE TAX AFFIDAVIT OF (Clerk of the Circuit Court & Comptroller, Palm Beach County)

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BROWSE CLERK OF THE CIRCUIT COURT & COMPTROLLER, PALM BEACH COUNTY FORMS

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L
ERKOFT
H
EC
IRCU I
TCOU
RT &
COMPTRO
LL
ER
PALM BEACH
COUNTY
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□
□
________________________________________________________________________
________________________________________________________________________
______________________ ________________________________________________
______________________ _________________ _______________ __________
C
PALM BEACH COUNTY PUBLIC SERVICE TAX
AFFIDAVIT OF SALES
Section 17-228 of the Palm Beach County Code
To Whom It May Concern:
Date: _______________
From: ____________________________
Subject: Palm Beach County Public Service Tax
Metered and Bottled Propane and Natural Gas/Electricity
Please be advised that ________________________
Company name
located at ___________________________
St Address, City, State, Zip
Sells or delivers within the unincorporated area of Palm Beach County.
Located within a Municipality and does not sell or deliver into unincorporated Palm Beach County.
Located in another County and does not sell or deliver into unincorporated Palm Beach County.
Comments:
I certify to the accuracy of this report:
Name of Company Street Address Store #, City/State Zip Telephone/Email ,/
Print Authorized Name Authorized Signature
Title Date
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PALM BEACH COUNTY PUBLIC SERVICE TAX AFFIDAVIT OF (Clerk of the Circuit Court & Comptroller, Palm Beach County)

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Completed 5 July 2021

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