Form D14 866 PDF Details

Form D14 866 is a tax form used to report the sale or exchange of certain capital assets. This form must be filed by the taxpayer within 30 days of the sale or exchange. The purpose of this form is to report the proceeds from the sale or exchange, as well as any related expenses. Failure to file this form may result in penalties and interest charges. taxpayers should always consult with a tax professional to ensure they are filing all required forms.

QuestionAnswer
Form NameForm D14 866
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesrev 1 2017 d14 866, APPT, rev 7 2014 d14 866, rve d14 866

Form Preview Example

MILEAGE REIMBURSEMENT

Social Security #:

Employee:

Employer:

Date of Accident:

**PLEASE COMPLETE EACH SECTION OF THE

FORM FOR EACH DAY MILEAGE REIMBURSEMENT IS BEING CLAIMED

 

NAME AND ADDRESS OF PHYSICIAN

 

DATE (S)

 

ADDRESS CLAIMANT STARTED FROM:

 

ADDRESS OF FINAL DESTINATION

 

ROUND TRIP

 

OR MEDICAL FACILITY:

 

 

 

 

 

 

 

 

 

AFTER DR’S APPT:

 

MILES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE DO NOT WRITE IN THIS SPACE

 

 

 

 

 

 

 

 

 

 

 

I WISH TO BE REIMBURSED FOR THE MILEAGE AT THE PREVAILING RATE OF

 

CENTS PER MILE

 

 

 

 

 

 

 

 

Any person who knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company or self-insured program

files a statement of claim containing any false or misleading information is guilty of felony of the third degree.

Mail to: Division of Risk Management

Claimant’s Signature:

 

 

 

 

 

Bureau of State Employees’ WC Claims

Street Address:

 

 

 

 

 

P.O. Box 8020

City/State/Zip

 

 

 

 

 

Tallahassee, Florida 32314-8020

Date:

 

 

 

 

 

REV 3/26/1999

D14-866

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