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

What Is Form DFS-H2-1106?

This is a legal form that was released by the Florida Department of Financial Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2002;
  • The latest edition provided by the Florida Department of Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DFS-H2-1106 by clicking the link below or browse more documents and templates provided by the Florida Department of Financial Services.

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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