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NOTICE OF ELECTION TO BE EXEMPT — Page 2 SECTION 9. FRAUD NOTICE A. Any person who, knowingly and with intent to injure, defraud, or deceive the department or any employer or employee, insurance company or any other person, files a notice of election to be exempt containing any false or misleading information is guilty of a felony of the third degree. B. Attestation of applic ; - By signin ,_ glow, I attest that I have read, understand and acknowledge the foregoing notice. IIL SI ' A • OF APPLICANT 11 11 \ SECTION 10. You must identify the workers' compensation insurance carrier that covers any non - exempt employees of your business. Carrier Name: 1•.• d ��. � Ik\ moo AFFIDAVIT OF APPLICANT: I hereby certify that the information contained herein is true and correct to the best of my 1 . • , ledge and belief that this election does not exceed exemption limits for corporate officers, including any affiliated co • <\ I as • "vie ' §440.02 Florida Statutes. APPLICANT'S SIGNATURE DATE SI NED NOTARY STATE OF FLORIDA, COUNTY + ` Sworn to and subscribed before me this 3u day of L 0k) 4 , ooi , by ,e2cc -- r - Personally Known ✓R Produced Identification Type of Identification Produced Ado, — J i NOTARY SIGNATURE _ l e. . A � / 0 or, My Commission Expires 9 (3 / Please mail or submit your completed application, application fee, d any required attachments to The Division of Workers' Compensation at the district office nearest your place of business. STATE USE ONLY Effective/Issue Date: 2295 Victoria Avenue, Suite 163 921 North Davis Street 401 NW 2^d Avenue Ft. Myers, FL 33901 Building B, Suite #250 Suite #321, South Tower Telephone (239) 461 -4006 Jacksonville, FL 32209 Miami FL 33128 Expiration Date: Telephone (904) 798 -5806 Telephone (305) 536-0306 610 E. Burgess Road Pensacola, FL 32504 - 6320 400 West Robinson Street TALLAHASSEE SUBMITTERS Control Number: Telephone (850) 453 -7804 Room #512, North Tower Orlando FL 32801 Wady -in submissions: 3111 S. Dixie Highway, Suite # 123 Telephone (407) 835-4406 or 2012 Capital Circle SE Postmark Date: West Palm Beach FL 33405 (407) 245 -0896 Suite #102, Hartman Bldg. Telephone (561) 837 -5716 Tallahassee FL 32399 -2161 499 Northwest 70th Ave., Suite # 116 Telephone (850) 413 -1609 Payment Number: 1313 N. Tampa Street, Suite # 503 Plantation FL 33317 Tampa FL 33602 Telephone (954) 321 -2906 Mail in submissions Telephone (813) 221 -6506 200 East Gaines Street Received Date: Live Oak Business Center Tallahassee FL 32399 -4228 1111 NE 25th Ave., Suite # 403 5969 Cattlemen Lane Telephone (850) 413 -1609 Ocala FL 34470 Sarasota FL 34232 Telephone (352) 401 -5350 Telephone (941) 329 -1120 "The collection of the social security number on this form is specifically authorized by Section 440.05(3), Florida Statutes. The social security number will be used as a unique identifier in Division of Workers' Compensation database systems for individuals who have applied for and /or been issued a certificate of election to be exempt. It will also be used to identify information and documents in those database systems regarding individuals who have applied for and /or been issued a certificate of election to be exempt for internal agency tracking purposes and for purposes _ of responding to both public records requests and subpoenas that require production of specified CAROL SMIDDY documents. The social security number may also be used for any other purpose specifically ; 0 ;1 4 ?o ° �A Notary Public - State of Florida required or authorized by state or federal law." .` = My Commission ExpiresAug 13, 2(11 DWC 250, NOTICE OF ELECTION TO BE EXEMPT — REVISED 12!08; RULE 69L-6.009, F.A.C. "'",,a.... Bonded Through National Notary Assn.