REQUEST FORM FOR COMMERCIAL ENTITIES Date: Business Name: Requestors Name (must be an authorized officer or agent): Business Street Address: Mailing Address: Business Telephone Number: Statement of Specific Purpose for which Social Security number is needed and how the information will be used by requestor: (check one) [ ] Verification of the accuracy of personal information received by an entity in the normal course of business. [ ] Use in a civil, criminal, or administrative hearing. [ ] Insurance purposes. [ ] Use in law enforcement and/or investigation of crimes. [ ] Matching, verifying, or retrieving information. [ ] Research activities. [ ] Other. Please explain: I, the undersigned, agree that I am an authorized officer and/or agent of the above named entity and have requested social security number(s) for a purpose authorized under Florida law. I further agree that the above- stated purpose is true and accurate. Under penalties of perjury, I declare that I have read the foregoing [document] and that the facts stated in it are true. Signature For Office Use Only Date Request Received Date Request Completed Clerk Processing Request Any person who makes a false representation in order to obtain a social security number pursuant to CS/HB 1673, commits a felony of the third degree, punishable as provided in s. 775.082 or s. 775.83,F.S.