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\"OTICE OF ELECTIO~ TO BE EXEiVIPT Please refer to the written instructions prepared by the Dh'ision of \Vorkers' Compensation before completing this form. ST ATE USE ONLY Eft~.;tive/[ssue Date: Expiration Date: By tiling this application, you elect to be exempt from the provisions of Chapter 440, Florida Statutes and waive any right you may have to workers' compensation benefits ill Control Number: the State of Florida should you become injured on the job. Anv oerson who knowinl!lv and with intent to iniure. defraud. or deceive the Division or any emoloyer. emplovee. or Postmark Date: insurance company or purposes oroeram. files a Notice of Election to be Exempt containine any false or mislead in!! information is l!uiltv of a felony of the third del!ree. Certain Received Date: documentation is required by law to be attached to this application-refer to the instruction sheet for more details. I am applying for exemption a, :> (check only one box in this section): ~o.)STRUCTIo.:\" INDVSTRY ( S 50.00 FEE REQUIRED) [i2t'Sole Proprietor 0 brtner [J ('r!'porate o.fficer (your corp. title:) -o.R- l'o.:\-Co.NSTRUCTIo.N INDUSTRY (NO. FEE REQUIRED) o Co orate Officer ( our co . title: CORPORATE OFFICERS AND PARTNERS: List the registration number of your business on file with the Division of Corporations, Department of State's Office (NOTE: your partnership may not have one, but all corporations must have one. If your partnership doesn't have one, state "N/A"): THIS EXEMPTION APPLICATION APPLIES ONLY TO THE PERSON SIGNING THE APPLlCA nON AND ONLY FOR THE BUSINESS ENTITY LISTED IN THE FOLLOWI~G SECTION Bu:fiess Name: Trade Name; d/b/a; or alk/a: -+" EL ~ Business Mailing ddress: g' Unemployment Compensation No. of Employees: Tax No: 0 Are you required to be registered or certified ursuant to Chapter 489, F. S.? DNo . es: list all certified or registered licenses issued to you pursuant to Chapter 489, Florida Statues C f\ Co D S ~ \ ~'3 Are you or a qualifier for your business required by the county or the municipality in which your business mailing address is located to have an occupational license for the business which is the subject of this application? D No Q'Yes: YOU MUST ATTACH A COpy OF A CURRENT OCCUPATIONAL LICENSE Are you ~1pj0Yed by any sole proprietorship, partnershi~. corporation or business entity other than the business to which this application applIes? ~NO 0 'YES I1st the name of all other busll1esses 111 which you are employed: Has the above-referenced business entity bee 'n operation long enough to have filed with or be required to file by the IRS, an annual Federal Income Tax Return? 1 fO 0 Yes, You must attach tax records. See instruction sheet for details, A FFIDA VIT OF APPLICANT: I hereby certify that the information contained herein is true and correct to the best of my kno\Yledge and belief; that this election does not exceed exemptioil limits for corporate ofl1cers or partners as provided in ~440.02 Florida Statutes; and that I will secure the payment of workers' compensation benetits, pursuant to Chapter 440, Florida Statutes, for any employee Inow have or may hereinafter acquire, for which my business is required by Florida law to secure such benel1ts. "II'. .? ..... '5 IDI '" ~ ! '-l L. 7 CO SOCIAL SECUUTY :-'-0. -1-1 20 I~_ DATE SIG:-'-ED \ I l I 7s OR EXDlI'TlO:-'- .. , mo. day DATE OF BIRTH. yr. A, COUNTY OF . il Sworn to :1nd subscribed before me lhis~ day of Person:1lly Known ~fl"~,-~ -i1.JD(by/1lh/r' c;;. LtJryJ~~< ' 'J .' V I , OR Produced IdentifiC:1tion ---- Type of Identific:1lion Produced r,j? ~_~ ~ J . c / xpires 7" / / & .I ~ p () V VERSE F~ ADDITIONAL'INFORt"IATIO~) (' l'\OTARY SIGNATURE -l LES FORt\I BCl\I-250 Revised February 00 \\;;'~"~/., l~''&.~" ~{~.~j ~"~iif..~~~" EC.JOHNSQ~EE MY COMMISSION # CC b45427 EXPIRES: September 16,2004 Bonded Thru NOlaI}' Public Undorwrit.,.