Form DFS-H2-1106 "Statement of Governmental Status for Agents and Customer Representatives" - Florida

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

The form was last revised in October 1, 2002 and is available for digital filing. Download an up-to-date Form DFS-H2-1106 in PDF-format down below or look it up on the Florida Department of Financial Services Forms website.

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Download Form DFS-H2-1106 "Statement of Governmental Status for Agents and Customer Representatives" - 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
AGENTS AND CUSTOMER REPRESENTATIVES
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
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
AGENTS AND CUSTOMER REPRESENTATIVES
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
Revised 10/02
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