Form DFS-H2-1106 "Statement of Governmental Status" - Florida

Form DFS-H2-1106 or the "Statement Of Governmental Status" is a form issued by the Florida Department of Financial Services.

Download a PDF version of the Form DFS-H2-1106 down below or find it on the Florida Department of Financial Services Forms website.

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Download Form DFS-H2-1106 "Statement of Governmental Status" - Florida

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DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building,
Tallahassee, FL 32399-0319
STATEMENT OF GOVERNMENTAL STATUS
Name
License ID Number
Documentation of government status as defined in Section 626.2815, F.S., must be attached.
To be eligible for credit, status must exist as of compliance date. Any change in the status
must be declared to the Department within 30 days of the change using this form. Status
date will be considered the signature date of the licensee on this form for any change in
compliance date.
Comments and related information:
Signature of Licensee
Signature of Employer
Date Signed
Date Signed
DFS-H2-1106
Rule 69B-228.180, F.A.C.
Revised 10/02
Print Form
DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building,
Tallahassee, FL 32399-0319
STATEMENT OF GOVERNMENTAL STATUS
Name
License ID Number
Documentation of government status as defined in Section 626.2815, F.S., must be attached.
To be eligible for credit, status must exist as of compliance date. Any change in the status
must be declared to the Department within 30 days of the change using this form. Status
date will be considered the signature date of the licensee on this form for any change in
compliance date.
Comments and related information:
Signature of Licensee
Signature of Employer
Date Signed
Date Signed
DFS-H2-1106
Rule 69B-228.180, F.A.C.
Revised 10/02
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