Fillable Division of Agent & Agency Services Bureau of (Florida Department of Financial Services)

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Division of Agent & Agency Services Bureau of (Florida Department of Financial Services)

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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
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Division of Agent & Agency Services Bureau of (Florida Department of Financial Services)

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Completed 20 November 2020

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