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I hereby certify that the information supplied with this filing does not qualify for the exemptions contained in Chapter 119, Florida Statutes. I hereby certify that the information indicated on this report or supplemental report is true and accurate and that my electronic signature shall have the same legal effect as if made under oath; that I am authorized to execute this report as required by Chapter 605, Florida Statutes; I am aware that false information submitted in a document to the Department of State constitutes a third degree felony as provided for in s. 817.155 , F.S. I authorize Florida Certified Document Services to submit this application on my behalf with the State of Florida
This signature must be that of the individual "signing" this document electronically or be made with the full knowledge and permission of the individual, otherwise it constitutes forgery under s. 831.06 , F.S. The individual "signing" this document affirms that the facts stated herein are true.
NOTICE Under s.817.155, F.S., a person may not:
Knowingly falsify or conceal a material fact,
Make a false, fictitious, or fraudulent statement or representation, or
Make or use any false document. Anyone violating these conditions is guilty of a third-degree felony and punishable by law. (s.775.082, s.775.083, or s.775.084, F.S.)