Dr 123 Form PDF Details

Did you know that your doctor's office may have a different name for their medical form? It's okay if you didn't, because today we're going to be talking about the Dr 123 Form. This form is used by doctors to collect important patient information, so it's important that you understand what it is and what it means for you.

Listed below are some specifics of dr 123 form. It's really worth finding the time to study this before starting submitting your form.

Form NameDr 123 Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesdr 123, dr123 fl, dr 123 fillable, florida dmv affidavit of correction

Form Preview Example

Partial Exemption for Motor Vehicle Sold

to Resident of Another State



R. 01/21

Rule 12A-1.097, F.A.C. Effective 01/21

State of Florida, County of ________________________________________

Name of Nonresident Purchaser _________________________________________________________________________________________

State of Residence and

Address of Purchaser __________________________________________________________________________________________________





If the nonresident purchaser is a corporation or partnership, an officer or partner

must acknowledge the following to qualify for the

partial exemption:




qThe vehicle will be removed from this state within 45 days of purchase and will remain outside this state for a minimum of 180 days.


If the vehicle is not removed from this state, an officer or partner in the nonresident corporation or partnership must certify the following:

qThere is no officer that is a resident of this state.

qThere is no stockholder who owns at least 10% of the corporation that is a resident of this state.

qThere is no partner in the partnership who has at least 10% ownership of the partnership that is a resident of this state.

Name of Seller ________________________________________________________________________________________________________

Address of Seller ______________________________________________________________________________________________________


Seller’s Sales Tax Registration Number_____________________________________ Date of Sale___________________________________

Description of Motor Vehicle:

Make___________________________________________Model __________________________________________Year__________________

Vehicle Identification Number _______________________________________ Motor Number ______________________________________

Sales Price________________________________________________________ Trade-In Allowance __________________________________

Florida Sales Tax Paid: ___________________________________________________________

This vehicle will be licensed in the State of ______________________ within forty-five (45) days after the date of purchase.

I, ___________(Purchaser's Initials) understand I may owe sales tax to the State of _________________________ where the vehicle

will be registered or licensed:

if a credit for sales tax paid to the State of Florida is not allowed, or

if the tax rate is higher than 6%.

I understand sales tax is being paid to the State of Florida and not to any other state.

Note: Tax Information Publication Motor Vehicle Sales Tax Rates by State is available on the Department's website at

floridarevenue.com/taxes/tips .

Sworn to (or affirmed) and subscribed before me by means of __ physical presence or __ online notarization on this _____________ of


_______,_______, by ____________________________ (nonresident purchaser).

(Month) (Year)



Signature of Nonresident Purchaser

Signature of Notary Public

Personally known ____________________________________ Or,


Produced identification __________________________________



Print, Type or Stamp Commissioned Name of Notary Public

Type of identification produced __________________________


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