EFTA00085931
GT-500002
N. 05/02
## Suggested Format for Affidavit for Exemption of Aircraft Sold for Removal from the State of Florida by a Nonresident Purchaser
The following is a suggested format of an affidavit to be completed by the purchaser and furnished to the selling dealer. In order to satisfy the requirements for exemption, the affidavit must contain all of this information and be completed in full.
STATE OF Florida COUNTY OF Broward
## *** READ CAREFULLY BEFORE SIGNING ***
Before me this day appeared the affiant named below, who being duly sworn, states that:
1. I have read Rule 12A-1.007(10), Florida Administrative Code, and § 212.05, Florida Statutes; and
2. I am not a resident of the State of Florida and did not make my permanent place of abode in Florida at the time of taking delivery of the aircraft described below; and
3. I am not engaged in Florida in any employment, trade, business, or profession for which the described aircraft will be used in Florida; and
4. I do not represent a corporation which has any officer or director who is a resident of Florida, or makes his or her permanent place of abode in Florida; and
5. I do not represent an artificial entity other than a corporation which has any individual vested with authority to participate in the management, direction, or control of the affairs of the entity who is a resident of Florida or makes his or her permanent place of abode in Florida; and
6. I agree to furnish the Florida Department of Revenue (within 30 days of the date of departure) written proof that this aircraft was licensed, titled, or registered outside Florida; and
7. I agree to furnish the Florida Department of Revenue (within 10 days of the date of departure) invoices for fuel, tie-down or hangar charges, repairs, or other similar documentation issued by an out-of-state vendor or supplier which identifies this aircraft and its timely removal (including the FAA registration number).
## PLEASE TYPE OR PRINT THE FOLLOWING INFORMATION:
| Name of purchaser | Industrial Integrity Solutions, LLC | SSN |
| :--- | :--- | :--- |
If purchaser is a corporation or partnership, list officers or partners ___ T.I.N.
(City) ___ (State/Country) ___ (ZIP) ___
Purchaser's daytime telephone number (___) ___ D.O.B. ___
Purchaser's driver's license number and state of issuance___
Purchaser's passport or visa number ___
Name of selling dealer or broker ___
Address of selling dealer (Street) ___
(City) ___ (State/Country)___ (ZIP) ___
Selling dealer or broker's Florida certificate of registration number ___
Selling dealer or broker's telephone number( ___ )___
Date of sale (Month) \_\_\_ MAY (Day) \_\_\_ (Year) \_\_2021
(continued on reverse side)
EFTA00085932
## Description of Aircraft
FAA registration number N722JE
| | | |
| :--- | :--- | :--- |
| (Check one) | New □ | Used ☑ |
| Purchase price $ | 1,800,000.00 | Trade-in $ | Net purchase price $ |
Primary location of aircraft while in Florida KFXE AIRPORT
I claim exemption from Florida sales and use tax on the purchase price of the aircraft described herein under s. 212.05(1)(a)2, Florida Statutes, for the following reason (check one):
The aircraft will be removed from Florida within 10 days of the date of purchase.
The aircraft requires repairs, additions, or alterations and it will immediately be taken to a repair facility and will be removed from Florida within 20 days (excluding tolled days) after completion of the work.
Under penalty of perjury, I declare that I have read the foregoing and the facts alleged are true to the best of my knowledge and belief. I understand that if I fail to comply with the requirements of this affidavit, I will be liable for payment of the tax and a mandatory penalty equal to the tax.
Signature of affiant/purchaser
Sworn to (or affirmed) and subscribed before me this day of ___ , ___ .
Signature of Notary
Print, type, or stamp name of Notary
□ Personally known
□ Produced identification
Type of Identification: ___
## Distribution of Documents
The original affidavit and a copy of the sales invoice, bill of sale, or closing document must be sent to the Florida Department of Revenue, Aircraft Enforcement Unit, P.O. Box 6417, Tallahassee FL 32314-6417 within five (5) days of the date of sale.
A copy of the affidavit must be retained by the selling dealer and made a part of the dealer's records.
The selling dealer or broker should provide the purchaser with a copy.
## Notice To Dealers
Affidavits not filed within five (5) days of the date of sale may not be accepted by the Department of Revenue and the selling dealer or broker may be billed for tax, penalty, and interest due.
| EFTA00085933 |
| :--- | :---
# ACKNOWLEDGMENT
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
County of SAN BERNARDINO)
On MAY 7, 2021 before me, JULIAN CARLOS GONZALES, Nutty Public (insert name and title of the officer)
(insert name and title of the officer)
personally appeared RICHARD MUNKVOLD
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature (Seal)