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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 applicant - By signing below, I attest that I have read, understand and acknowledge the foregoing notice. SIGNATURE OF APPLICANT SECTION 10. You must identify the workers' compensation insurance carrier that covers any non - exempt employees of your business. Carrier Name: /v /A AFFIDAVIT OF APPLICANT: 1 hereby certify that the information contained herein is true and correct to the best of my knowledge and belief; that this election does not exceed exemption limits for corporate officers, including any affiliated corporations as provided in §440.02 Florida Statutes. APPLICANT'S SIGNATURE DATE SIGNED NOTARY STATE OF OF Jt,..v Sworn to and subscribed before me this`' day of N 1 c. s -1 Personally Known .7 : • • , - - • : ; . -- . . _ • * ubtic - North Carolina Produced Sorry County NOTARY SIGNATUR on D i -25 c 'K-4-- c c._ (—o .� My Co , iij1, Z�:ii ii�+;L ` Please mail or submit your completed application, application fee, and any required attachments , to The Division of Workers' Compensation at the district office nearest your place of business 2295 Victoria Avenue, Suite 163 921 North Davis Street 401 NW 2^d Avenue Effective/Issue Date: Ft Myers, FL 33901 Building 8, Suite#250 Suite #321, South Tower Telephone (239)461-4006 Jacksonville, FL 32209 Miami FL 33128 Telephone (904) 798 -5806 Telephone (305) 536 -0306 Expiration Date: 610 E. Burgess Road Pensacola, FL 32504 -6320 400 West Robinson Street TALLAHASSEE SUBMITTERS Telephone (850)453 -7804 Room #512, North Tower Control Number: 3111 S. Dale Highway, Suite # 123 Orlando FL 32801 Waikvn submissions West Palm Beach FL 33405 Telephone (407) 835.4406 or 2012 Capital Circle SE Postmark Date: Telephone (561) 837 -5716 (407) 245-0896 Tallahassee F Hartman 4389 2961 1313 N. Tampa Street, Suite #543 4 99 Northwest 70* Ave., S uite # 11 6 Telephone (850) 413 -1609 Tampa R 33602 Plantation FL 33317 Payment Number Telephone (813) 221 -6506 Telephone (954) 321-2906 A4sHin submissions: Live Oak Business Center 200 East Gaines Street Received Date: 1111 NE 25" Ave., Suite # 403 5969 Cattlemen Lane Tel h one (850 413 13413 -16228 Ocala FL 34470 Sarasota FL 34232 phone (609 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 appfied 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 documents. The social security number may also be used for any other required or authorized by state or federal law." y purpose specifically DIMC 250, NOTICE OF ELECTION TO BE EXEMPT- REVISED 12109; RULE 591-8.009, F.A.C.