Instructions:
  1. All fields must be completed to process the form.
  2. A separate form must be submitted for each agency whose payments resulted in disputed fees.
  3. Completed forms should be submitted to .
  4. If you have questions, please contact the MyFloridaMarketPlace (MFMP) Customer Service Desk at 1-866-352-3776 or .
Dispute Request Information:
Date: / Click here to enter text. /
Federal Tax ID #*: / Click here to enter text. /
Company Name: / Click here to enter text. /
Contact Name: / Click here to enter text. /
Title: / Click here to enter text. /
Phone Number: / Click here to enter text. /
Contact Email: / Click here to enter text. /
State Agency: / Click here to enter text. /
Consolidated Billing Invoice (CBI) Number / CBI Date / Purchase Order (PO), Contract or Invoice Number / Total Payments from the state / Disputed Fee Amount
(value of the transaction fees) / Reason for Dispute
For example: 9003492 / For example: 6/1/2013 / For example: AZ12345 / For example:
$70,000 / For example:
$490 / For example:
Exempt service, construction
Click here to enter text. / Click here to enter a date. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter a date. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter a date. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Total Amount Disputed / $Click here to enter text. / $Click here to enter text.

For Agency Transaction Fee Dispute Liaison

Reviewer Name: / Click here to enter text. / Approved: ☐Yes ☐No
Date Reviewed: / Click here to enter a date. / Exemption Reason Code: Choose an item.
See listing of reason code descriptions on following page.
Comments: / Click here to enter text. /
Approval of this form does not exempt any remainingPO, contract or invoice balance associated to this order. To prevent further assessment of fees, process a change order,check the ‘Transaction Fee Exempt?’ box, and select the appropriate exemption reason in the Accounting Details. Customers must have the ‘Transaction FeeExempt’ permission to mark a transaction fee exempt. If you are unable to edit this field, contact your agency’s MFMP System Administrator.

Transaction Fee Exemption Codes and Definitions

Exemption Code / Exemption Reason / Notes
3A / Procurement under Section 337.11 Florida Statutes / Construction
3B / Procurement under Section 287.055 Florida Statutes / Professional architectural, engineering, landscape architectural, or surveying and mapping services
3C / Procurement under Chapter 255 Florida Statutes / Public Property And Publicly Owned Buildings
3D / Transaction with Non-Profit Entity
3E / Transaction with another Governmental Agency
3F / Transaction with required Sole Provider or price paid and payee established by federal or private grant
3G / Payment to Unregistered Vendor under Rule 60A-1.033(3)
3H / Payment to vendor in exchange for providing health care services at or below Medicaid rates
3I / Disbursement to Recipient or Sub-Recipient; payment to satisfy Maintenance of Efforts requirement; or payment to match federal award
4 / The transaction is critical to Agency's mission or necessary for public health, safety,orwelfare; and imposition of the fee would prevent the consummation of the transaction
5A / Emergency Transaction per Rule 60A-1.031(5)(a) / When the governor suspends purchasing regulations due to an emergency
5B / Emergency Transaction per Rule 60A-1.031(5)(b) / When the agency head declares an emergency

Last updated 10/2017