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NOTICE OF ELECTION TO BE EXEMPT ^; read the instructions before compacting this application. Print legibly in each data entry field. If this application contains incomplete or ,,dormation or if the handwriting is not legible, it may cause n delay in the issuance of your exemption. ON 1: 'Applicant Name (please print): 1J f) Al7r) Sice_ . Applicant's social security number: - g CP f / 04 -1 / 5Z.9 Applicant's E -mail address (optional): bit°.S kt: (%. - a M)61 ban n rC CO1V1 SECTION 2: I am applying for exemption as a (You must check only one box in this section): CONSTRUCTION INDUSTRY (S50 FEE REQUIRED) - The Division will accept a money order or a cashier's check made payable to the DES WC ADMINISTRATION TRUST FUND. ❑ Officer of a Corporation (Title): -OR- [ Member of a Limited Liability Company (LLC) NON- CONSTRUCTION INDUSTRY (NO FEE REQUIRED) , ` ❑ Officer of a Corporation (Title): • ) An officer electing an exemption under Chapter 440, Florida Statutes is not entitled to benefits under this chapter. SECTION 3. The corporation of which you are an officer or the limited liability company of which you are a member must be registered and in an active status with the Florida Division of Corporations. Applicants applying as an officer of a corporation must be listed as an officer of the Corporation with the Florida Division of Corporations. List the document number (document number shown on our Annual Report) on file with the Florida Division of Corporations.. LOBOuoO( 30$ I )31(k SECTION 4. This exemption application applies only to the person signing the application, the Corporation/LLC that is listed below, and the scope of business or trade listed: Name of Corporation or LLC: ' (1 �. cn on WC- FEIN: gOOZO 5g UUUUUU AS REGISTERED WITH THE FLORIDA DIVISION OF CORPORATIONS Business Name: Phone: (813 ) 3 IF APPLICABLE - LIST FICTITIOUS NAME; DOING BUSINESS AS (DBA); ALSO KNOWN AS NAME (AKA) Applicant's Address of Record: ) Z-1Z ga Clot? Gir o) INCLUDE APARTMENT OR SUITE NUMBER ,1 i City: ) G i✓) pCq State: FL Zip: 3 3 ( 7 County: PIA Orot-91 Scope of Business or Trade: 1. co it C 0.4er t*r 2. ( - L ! t hL ,-. 3. RePGAI : 4. 2eivictki SECTION 5. List all certified or registered licenses issued pursuant to Chapter 489, F.S. held by the applicant, or the certified or registered license numbers held by the qualifier for the c• • .lion or LLC listed on this application of which the applicant is a corporate officer: C. C7 e; .. . 1 S 1 S 1 Co a ria SECTION 6. If you have submitted an electronic payment for this application, write the transaction confirmation number in the following space: SECTION 7. Are you affiliated with any corporation (including LLC) other than the corporation (including LLC) to which this application applies? ❑YesJNo IF YES, PLEASE LIST THE NAME(s) AND FEIN(s) OF THE AFFILIATED CORPORATION(s) OR LLC(s): NAME: FEIN: SECTION 8. If your corporation or LLC is engaged in the construction industry, you must provide the required proof of ownership in the corporation or LLC. A. To be eligible for a construction industry exemption as an officer of a corporation, the applicant must be a shareholder, owning at least 10% of the stock of the corporation. A COPY OF A STOCK CERTIFICATE EVIDENCING THE REQUIRED OWNERSHIP MUST BE ATTACHED. B. To be eligible for a construction industry exemption as a member of a limited liability company, the applicant must • confirm ownership of at least 10% of the company. THE REQUIRED OWNERSHIP MAY BE ESTABLISHED BY PRODUCTION OF DOCUMENTATION REFLECTING THE REQUIRED OWNERSHIP, OR BY SUBMITTING A STATEMENT ATTESTING TO THE REQUIRED OWNERSHIP. THIS APPLICATION IS CONTINUED ON PAGE 2 DWC 250, NOTICE OF ELECTION TO BE EXEMPT - REVISED 12108; RULE 69L- 6.009, F.A.C.