Free Request for Duplicate Exemption - Florida

REPRESENTING

ALEX SINK
CHIEF FINANCIAL OFFICER STATE OF FLORIDA

REQUEST FOR DUPLICATE EXEMPTION
SECTION 1. Name of Corporation or LLC: __________________________________________________ FEIN: _______________________ Applicant's Name:____________________________________________________Telephone: _(

)__________________
___________
ZIP STATE

Business Mailing Address: ____________________________________ _______ _________________ _____
STREET or PO BOX APT/STE# CITY

Reason For Duplicate Exemption: Original Certificate of Election To Be Exempt was: Never Received
Please Explain

Lost

Stolen

Destroyed

Other Reason: ______________________________________________________________________________________ SECTION 2. FRAUD NOTICE · · 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. Attestation of applicant - By signing below, I attest that I have read, understand and acknowledge the foregoing notice. _____________________________________________________________
SIGNATURE OF APPLICANT

AFFIDAVIT OF APPLICANT: I 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; and that any employees of the corporation or limited liability company (LLC) are covered by workers' compensation insurance.
_________________________________________________
TYPE/PRINT NAME OF PERSON APPLYING FOR EXEMPTION

_____________________________________________
APPLICANT'S SIGNATURE

____________________
DATE SIGNED

NOTARY STATE OF FLORIDA, COUNTY OF ________________________ Sworn to and subscribed before me this______ day of _______________, _________, by _____________________________ Personally Known______ OR Produced Identification_____ Type of Identification Produced____________________________ NOTARY SIGNATURE ____________________________________ My Commission Expires ________________________

PLEASE SEE INSTRUCTIONS FOR COMPLETING THIS FORM ON THE REVERSE SIDE
· · · DIVISION OF WORKERS' COMPENSATION · BUREAU OF COMPLIANCE 200 EAST GAINES STREET · TALLAHASSEE, FLORIDA 32399-4228 · (850) 413-1609 · FAX (850) 922-1028
Affirmative Action / Equal Opportunity Employer

INSTRUCTIONS
Only individuals who hold a valid Certificate of Election to Be Exempt, or a valid Re-Issuance of Construction Industry Certificate of Exemption should use this form. This form cannot be used to apply for a new exemption or to renew an exemption. SECTION 1: A. List the name, of the Corporation or Limited Liability Company as it appeared on the original Certificate of Election to Be Exempt. B. List the completed 9 digit Federal Employer Identification Number (FEIN) belonging to the Corporation/Limited Liability Company. C. List the name of the person as it appeared on the original Certificate of Election to Be Exempt. D. List a daytime telephone number, including area code, where someone can be reached regarding any questions that may arise. E. List the complete business mailing address including apartment or suite number. This will be the address to which the duplicate Certificate of Election to Be Exempt will be mailed. Please remember to contact the Division whenever there is a change of address so that our records will remain current. F. Please provide the reason for requesting a duplicate Certificate of Election to Be Exempt. SECTION 2: FRAUD NOTICE Each applicant must read the fraud notice and provide his or her signature in the appropriate area. The signature is an attestation that the fraud notice was read, understood and acknowledged. AFFIDAVIT OF APPLICANT An affidavit is a sworn statement in writing made under oath or on affirmation before an authorized officer. This section should be completed after careful review of the statement being attested to. Type or print your name in the space provided. The application should not be signed or dated until you are in the presence of a notary public. NOTARY PUBLIC The Request For Duplicate Exemption application must be notarized prior to submission. Please assure that the Notary has signed in the proper area and stamped the document with their Notary stamp which contains their ID and expiration date. This application may be mailed or hand delivered to the District Office listed below that is closest to your business:

2295 Victoria Avenue Suite #163 Ft. Myers, FL 33901 Telephone (239) 461-4006 400 West Robinson St. Room #512 North Tower Orlando FL 32801 Telephone (407) 245-0896 Live Oak Business Center 5969 Cattlemen Lane Sarasota, FL 34232 Telephone (941) 329-1120 610 E. Burgess Road Pensacola FL 32504-6320 Telephone (850) 453-7804

921 N. Davis St. Building B, Suite #250 Jacksonville FL 32209 Telephone (904) 798-5806 1111 NE 25th Ave. Suite #403 Ocala FL 34470 Telephone (352) 401-5350 1313 N. Tampa St. Suite #503 Tampa FL 33602 Telephone (813) 221-6506

401 NW 2nd Ave. Suite #321 South Tower Miami FL 33128 Telephone (305) 536-0306 3111 South Dixie Hwy. Suite #123 West Palm Beach FL 33405
Telephone (561) 837-5716

TALLAHASSEE SUBMITTERS Walk-in submissions: 2012 Capital Circle SE Suite #102 Hartman Bldg. Tallahassee FL 32399-2161 Telephone (850) 413-1609 Mail in submissions: 200 East Gaines Street Tallahassee FL 32399-4228 Telephone (850) 413-1609

499 Northwest 70th Ave. Suite #116 Plantation FL 33317
Telephone (954) 321-2906