DULY AUTHORIZED REPRESENTATIVE (DAR)
This affidavit is required pursuant to the City of Tampa Private Provider Review and
Inspection Registration Program. F.S. 553.791 (8).
The authorization(s) for the listed individual(s) will remain in effect, unless cancelled in writing,
by the undersigned.
Private Provider Name (Printed): ___________________________________________________
Private Provider License No: __________________________________________________________________
I, , the Private Provider, do hereby affirm that the Duly
Authorized Representatives listed below are my employees, as required by Florida Statute
553.791 and are entitled to receive unemployment compensation benefits under Chapter 443.
Printed or Typed Name of Private Provider Signature of Private Provider
STATE OF FLORIDA
SWORN TO (OR AFFIRMED) AND SUBSCRIBED before me this day of ,
20 , by (name of person making statement).
Signature of Notary Public – State of Florida
Printed or Typed Name of Notary Public