I hereby certify that the information provided with this filing does not qualify for the exemptions contained in Chapter 119, Florida Statutes. I hereby certify that the information set forth in this report or supplemental report is true and accurate and that my electronic signature shall have the same legal effect as if it were made under oath; that I am an officer or director of the corporation or the trustee or receiver empowered to execute this report as required by Chapter 607, Florida Statutes; and that my name appears above, or in an attachment with all other similarly empowered persons. I am aware that false information submitted in a document to the Department of State constitutes a third-degree felony as provided in s. 817.155, F.S. This signature must be that of the person electronically signing this document or must be made with the person's full knowledge and permission; otherwise, it constitutes forgery under s. 831.06, F.S.

The person who prepares and signs this form states that he or she is the person, executor, guardian, authorized officer, or agent of the person who owns the mail handled to us by the US Postal Service. Anyone submitting false or inaccurate information on this form is subject to punishment by fine or imprisonment or both under Sections 2, 1001, 1702, and 1708 of Title 18, United States Code. (U.S.C.)