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Home My WebLink AboutDocumentation_Pension General_Tab 05_02/05/2007• Bi1SINESS SERVICES CONNECTION, INC. 260 RIVERSIDE DRIVE, PALM BEACH GARDENS, FL 33410 561-694-79tH Fax 561-694-1591 December 30, 2006 TO: Village of Tequesta Invoice No. 6-92 INVOICE • Attend General Employees' Pension Board meeting held November 6, 2006 and prepare minutes for the meeting. 6 hours @ $32.22 ...........................................................$193.32 Total Due .....................................................................$193.32 Please make check payable to: Business Services Connection, Inc. 260 Riverside Drive Palm Beach Gardens, FL 33410 • HANSON, PERRY $~ JENSEN, P.A. 4OO EXECUTIVE CENTER DRIVE, SUITE 2O7 -WEST PALM BEACH, FLORIDA 33401-2922 ~LHANSON* anson ®hpjlaw.com NN H. PERRY aperry ~ hpJlaw.com BONNI SPATARA JENSEN bsjensen ~ hpjlaw.com 'a~so A~.+me~ w N.Y. • • Via Email Village of Tequesta General Employees Pension Fund Betty I_aur, Pension Administrator Post Office Box 3273 250 Tequesta Drive, Suite 300 Tequesta, Fl_ 33469-0273 Dear Betty: January 18, 2007 TELEPHONE (561) 686-6550 FACSIMILE (561) 686-2802 Re: Hanson, Perry & Jensen Billing Statement Enclosed please find the Firm's invoice for services rendered for the period that ended 1/15/2007. Thank you for your payment of $806.50. Your current balance due is $221.00. If you have any questions, please do not hesitate to contact me. Sincerely, ,J Bonni S. Jensen BSJladi Enclosure Copy to: Robert Garlo, Chairman Via Regular Mail 4 13 rl l HANSON, PERRY & JENSEN, P.A. • 400 Executive Center Drive Suite 207 West Palm Beach, FL 33401 Phone: 561-68fi-6550 Invoice submitted to: General Employees Pension Fund Pension Administrator, Village of Tequesta -via email P.O. BOX 3273 250 Tequesta Drive, Suite 300 Tequesta FL 33469-0273 ATTN: Betty Laur /Copy to: Chairman January 17, 2007 I n Reference To: For professional services rendered as follows: Ciient /File No.: 1012 Previous balance Total payments Balance due Amount $1,027.50 ($806.50) $221.00 HANSON, PERRY $~ JENSEN, P.A. 40O EXECUTIVE CENTER DRIVE, SUITE 207 -WEST PALM BEACH, FLORIDA 33401-2922 ILL HANSON* ~anson®hpjlaw.com N H. PERRY aperry®hpjlaw.com BONNI SPATARA JENSEN bsjensen®hpjlaw.com 'aLSO AOMfT7E0 w N.Y. Via Email Village of Tequesta General Employees Pension Fund Gwen Carlisle, Pension Administrator Post Office Box 3273 250 Tequesta Drive, Suite 300 Tequesta, FL 33469-0273 Dear Gwen: December 19, 2006 TELEPHONE (561) 686-6550 FACSIMILE (561) 686-2802 Re: Hanson, Perry & Jensen Billing Statement Enclosed please find the Firm's invoice for services rendered for the period that ended 1211512006. Your current balance due is $1,027.50. • If you have any questions, please do not hesitate to contact me. Sincerely, ,, --~..~ Bonni S. Jensen BSJladt Endosure Copy to: Robert Carlo, Chairman Via Regular Mail • HANSON, PERRY ~ JENSEN, P.A. 400 Executive Center Drive • Suite 207 West Palm Beach, FL 33401 Phone: 561-686-6550 Invoice submitted to: General Employees Pension Fund Pension Administrator, Village of Tequesta P.O. BOX 3273 250 Tequesta Drive, Suite 300 Tequesta FL 33469-0273 ATTN: Gwen Carlisle /Copy to: Chairman December 19, 2006 In Reference To: For professional services rendered as follows: Client /Fife No.: 1012 Invoice # 61190 Professional Services Hrs/Rate Amount • Participant -General Correspondence 12/1 /2006 BSJ Review 0.30 51.00 Review email from Merlene Reid re: Florida Retirement 170.00/hr System Participant -General Correspondence 12!4/2006 BSJ Review 1.00 170.00 Review email from Merlene Reid 170.OOlhr Telephone call with Steve Palmquist . Research Refund of Contributions made by mistake E-mail to Merlene Reid Participant -General Correspondence SUBTOTAL: [ 1.30 221.00] For professional services rendered 1.30 $221.00 Previous balance $806.50 Balance due $1,027.50 • ~neral Employees Pension Fund Wishing you a safe and happy Holiday Season and a bright and prosperous New Year. • Page Bogdahn Consulting, LLC. • 340 West Central Ave Suite 300 Winter Haven, Fl 33880 Bill To • lJ Tequesta General Employee Pension Fund 250 Tequesta Drive Suite 300 Tequesta, F1 33469-2766 Invoice Date Invoice # 1/5/2007 2150 RECEIVED ~~-N 16 ~QO~' VILLAgE CLEt~KS OFFICE Description Amount Quarterly Fee for 10/01 /06 -12/31 /06 1,125.00 Balance Due $1,125.00 ~~ ~ ~ t ~~, ,.. 1).~~.~ I~~ i:,-i ~~~.~ 3 Ai~~~~~i~hti. lac: January 17, 2007 City of Tequesta For General Employees' Pension Fund (1087) Attn: gcarlisle@tequesta.org 250 Tequesta Drive Suite 300 Tequesta, FL 33469-0273 Dana Investment Advisors STATEMENT OF MANAGEMENT FEES For The Period 4th Quarter 2006 Trust #80105025 • Portfolio Valuation with Accrued Interest as of 12-31-06 $ 844,260.50 Fixed Holdings 352,724 @ 0.5000% per annum divided by 4 440.90 Equity Holdings 491,537 @ 0.7500% per annum divided by 4 921.63 Quarterly Management Fee $ 1,362.54 TOTAL DUE AND PAYABLE $ 1,362.54 Thank You. cc: Joe@BogdahnConsulting.com cc: Donna@BogdahnConsulting.com If you have any questions please call Jennifer ~ (262)7$2-3631. Payment to: Dana Investment Advisors, Attn: Jennifer, P.O. Box 1067 Brookfield, I, 53008-1067. Thank You • r+'-' ~ ~.. C O M P A N Y 455 Fairway Drive, Suite 103 Deerfield Beach, FL 33441 (954) 725-4490 Village of Tequesta Atten: Jody Forsythe 250 Tequesta Drive Suite 304 Tequesta, Florida 33469-0273 LL~ t~ Q ~S ~..{ Janua~ 3, 2007 C- A/C 80105025 Tequesta GE EE's Pension Fee Advice for Period October 1, 2006 to December 31, 2006 Total Market Value for Fund: $ 839,476.20 Detail of Calculation: Market Value • Market Value Fee Basis Point Rate 0.0004 $ Annual Fee 335.79 Quarterly Fee $83.95 Security Transactions 52 $ 10.00 $ 520.00 $520.00 Lump Sum Distributions 0 $15 $ - $0.00 Invoice Payments 4 $ 15.00 $ 60.00 $60.00 Fee for Quarter $663.95 Minimum Annual Fee $1,500 TOTAL FEE for QUARTER $663.95 THIS IS NOT AN INVOICE -PLEASE DO NOT SEND PAYMENT UNLESS YOU WISH TO REIMBURSE THE ACCOUNTS. These fees will be charged to the accounts referenced in the month following the period end. If you have any questions call your account administrator: Karen Russo • REVENUEIEXPENDITURE REPORT Village of Tequesta Page: 1 For the Period: 1011/2005 to 9/30/2006 12/7/2006 3:41 pm Original Bud. Amended Bud. YTD Actual CURR MTH Encumb. YTD UnencBal % Bud 001 -General Fund Expenditures Dept: 160 General Govemment Acct Class: 530 Operating Expenditures/Expense 545.300 Insurance 10/01!2005 GJ OCT OS PRE PYMT -INSURANCE PARTNE LIABILITY INS ~-3631.12 3,631.12 11/23/2005 AP ACORDIA SOUTHEAST POLICY#CPP001750010, FY O6 654.00 INV#: 11102005 39382 11/23/2005 AP ACORDIA SOUTHEAST POLICY# PKFL105025050504 FY O6 10,500.00 INV#: 10052005 39411 07/27/2006 BA PER RES # 88-05106, FUNDING FOR -NSURANCE EXPENSES IN FY 2006 8,586.00 09/07/2006 AP ACORDIA SOUTHEAST #CCP001750012, FY 2007 657.00 INV#: 09062006 44044 Insurance 6,200.00 14,786.00 15,442.12 657.00 0.00 -656.12 104.4 Operating ExpendituresJExpense 6,200.00 14,786.00 15,442.12 657.00 0.00 -656.12 104.4 General Govemment 6,200.00 14,786.00 15,442.12 657.00 0.00 -056.12 104.4 Expenditures 6,200.00 14,786.00 15,442.12 657.00 0.00 -656.12 104.4 Net Effect for General Fund -0,200.00 -14,786.00 -15,442.12 -657.00 0.00 656.12 Change in Fund Balance: 0.00 • ~' 2007 ~k-~ke -I~~aM Ne~s~n iZl~ ~oco - -Ti~,i s -I -fir ~Iw V~Ilaaaa of - ~, tin -~i,~nds. Sko ~,,~ q(e co~e~ed~ er~c~(I~ i• a~i- ~ i~c{.zs Coi - ~ iey.2s (off 3 - ~ I (~L~. ZS cow S ~~~ -~~ ~~hes vp~~uw, tvtiiy /'~VVRLJI/'1 JVV II IL~f1J1 Invoice # Invoice Date 09062006 ~ ~ 09/06/2006 Description #CiCP001750012, FY 2007 Distribution Gross: Check Amt Total: .7 I Check Date: 09/14/2006 Amount 657.00 657.00 Check #: 72847 Check Date: 09/14/2006 Check #: 72847 $657.00 SIX HUNDRED FIFTY-SEVEN DOLLARS AND 00 CENTS**********************+********** ORDIA SOUTHEAST . BOX 4237 ST PALM BEACH FL 33402 REQUESTS RECEIVED IN FINANCE BY TUESDAY AT 5:00 PM WILL BY AVAILABLE FOR DISrR1BUTION BY THE FOLLOWING MONDAY AT NOON • PLEASE PLAN YOUR REQUESTS ACCORDINGLY! WP801M~Ia~Checlc Request 501 South Flagler Drive Suite 600 West P91m Beach, FL 33401 Voice: 561.655.5500 Fax: 561.655.5509 www.acordia.com August 8, 2006 ®an Gallagher 'Village of Tequesta P.O. Box 3273 Tequesta, FL 33469-0273 RE: Crime Policy #CCP001750012 Policy Term: 10/1/2006 - 10/1/2007 Dear Dan: • The Crime policy was automatically renewed for the term referenced above but the carrier needs the enclosed renewal application completed. The application has been partially completed for you. Please complete page 2 and sign page 5. We need the original signed application returned no later than 8/25/06. Please call us if you have any questions Sincerely, ~~ INV. DA INV #.,~------.-.~... A CT# - D AIt Z3 ~ DATE Pamela Poe, AAI Account Manager RF7.C -.~`~.'°" FINANCE APP .~ G ~ ~ ,.° _. , i• /A Wells Fargo Company • Member of u,e ~glabat Network Policy No. CCP 0017500 12 FIDELITY AND DEPOSIT COMPANY OF MARYLAND ~ Administrative OfT~s e D 1400 American Ln ~~,„~ COLONIAL AMERICAN CASUALTY AND SURETY COMPANY Schaumburg, il_ soles APPLICATION FOR A COMMERCIAL CRIME POLICY FOR COMMERCIAL AND GOVERNMENT ENTITIES A9pfi~ation is herby made by 1 /Qi d~ ~U_~~`~4- - ~ (List all i uned, inci ing Employee Benefits Plans) ~I ~~ ~±~i~j S(6 i'~ T Mailing Address to _ (No.) (Street) (City) (County) (State) RIP) AppNcant's E-mail/Website Address for a Commercial Crime Policy to become effective or to be continued as of 12:01 a.m. on - ~ Name and address of obligee if other than Insured: Nam) limit of Deductible Agreement 1 -Blanket -Employee Theft Insurance Amount s ~8~~ s 2,.s-a Agreement 2 -Forgery or Alteration $ $ Agreement 3 -Inside The Premises -Theft of Money & Securities ^ Blanket ^ Schedule $ a ~reement 4 -Inside The Premises -Robbery Or Safe Burglary Of Other property ^ Blanket ^ Schedule $ $ Agreement 5 -Outside The Premises -Theft of Money 8 Securities And Robbery of Other Property ^ Blanket ^ Schedule $ ~ Agreement 6 -Computer Fraud 3 $ Agreement 7 -Money Orders And Counterfeit Paper Currency $ 3 Other Coverages/Endorsements Umit of Deductible Insurance Amount s ~ s s s $ $ ~ s $ Is Faithful Performance of Duty coverage, as prescribed ny law or your constitution and by-laws, requested? ,~ Yes ^ No Premium Payable: Annual DThree year prepaid DThree year in equal annual installments DESCRIPTION OF YOUR ORGANIZATION: 1. Classify your predominant activity: Manufacturer ^ Processor ^ Retailer ^ Servicer ^ Govemmental~ Other ^ (explain) 2. Describe the products and services of your predominant business or activity 3. Are you a Proprietorship ^ PaMershi PD Corporation OtherQ a. If a corporation, does any employee own more than 50% of the stock? Yes ^ If "Yes", give name and percentage: t. Number of additional locations? Retail Not Retail ~e you were established ~_ Wholesaler D DisUibutor ^ No ;CR 4724m (Ed. 03-02) Page 1 of 5 • 6. • Are there any foreign locations? ^ Yes ~-do tf "Yes', list countries and number of empbyees: ~nt-y No. of Employees ~ 1. 2. 3. 4. 5. 6. T. 8. 1. 2. AUDIT PROCEDURES AND INTERNAL CONTROLS IF A QUESTIQN IS ANSWERED 'NO", EXPLAIN WHAT ALTERNATE CONTROL IS IN EFFECT (ATTACH SEPARATE SHEET WITH EXPLANATIONS) Do you have a CPA Audit, at least annually, made in accordance with generally accepted auditing standards and so certified? ..................................................................._......._.................._......................---......... Are bank accounts reconciled monthly by someone not authorized to deposit or withdraw therefrom? ...................... Is vountersignature of checks recluired7 ................................................................................ Are incoming checks immediatey stamped "For Deposx Ony b the credit of applicant? ......................................... Are all deposits made in the name of applicant? ..............................-.....__........................_..............._... Are securities subject b joint control by two or move r~esponsrble empbyees? ................................................. . ... Is an inventory of merchandise taken at least annuaNy't.......---. ....................... Is at least one wntinuous week of vacation taken annuaNy by aN employees? ............................. COMMERCIAL EMPLOYEE CLASSIFICATIO Number of Officers N~ Number of empbyees in the following dassifiptions: 1" No. of I No. of Accountants and Asst Accountants Adjusters Administrators and Asst. Adminiistrators Appraisers and Clerks acting as Appraisers Altomeys Auditors and Asst. Auditors Bookkeepers Bursars and Asst. Bursars Bus Drivers Buyers and Asst Buyers Canvassers (door-to-door Salespeople) Cashiers and Asst Cashiers Chairpersons Chefs who order food Collectors ComputJer Programmers ComptroNers and Asst. Comptrollers Credit Clerks and Managers Cusbdians Flood Inspectors Head Phamracists Instrucbrs having custody of money or securities Janitors Ledger Keepers Locker Room Attendants Maitre d's and Asst Maitre d's Managers and Asst Managers Medical Directors Messengers, outside PayroN Distributors Purchasing Agents and Asst Purchasing Agents Yes Yes Yes ^ Yes Yes ~ Yes ^ Yes ^ Yes No[ No[ Nod NoQ NoQ No^ No. of Receiving Clerks Salespeople Securit)- Personnel Service Statbn Attendants Shipping Clerks Stock Clerks Storekeepers Storeroom Personnel Superirrtendents ar~d Asst Superintendents Supervisors and Asst. Supervisors Tad Drivers Timekeepers. Truck Drivers Warehouse Personnel Ad other employees not listed who handle, shave custody or maintain reoonis of money. securiiee or other property. 3. Number of all other empbyees GOVERNMENTAL EMPLOYEE CLASSIFICATION Note: Persons required bylaw to be individually bonded and treasurers or tax collectors by whatever title known are automatically excluded from coverage under the Government Crime Policy. 1. Number of officiaWofficers, not required by law to be individually bonded, who are authored to manage, govern or control the sured's employees ~_ tuber of empbyees who handle, have custody or maintain records of money, securities or other property; department and division ds; assistant department and division heads; and peace officers including patrolmen when Faithful Performance of Duty Coverage is being written) ~_ 3. Number of all other employees (including patrolmen, when written for Honesty Coverage only) ¢! ~CR 4724m (Ed. 03-02) Page 2 of 5 `" I~ MONEY -SECURITIES ENTEF. THE EXPOSURES FOR EACH CATEGORY. AMOUNTS ENTERED SHOULD BE MAXIMUM EXPOSURE TYPE MONEY CHECKS FOR CHECKS FOR PAYROLL DEPOSIT ACCOUNTS PAYABLE CHECKS PROPERTY MONEY I SECURITIES OVERNIGHT nN e4N1C/SAFC nci GENERAL INFORMATION AVGIi CHECKS FREQUENCY RIGHT ANNUAL GROSS SALES DOES PREMISES BUSWESS HOUR8 EMPLOYEES STAMPED FOR OF DEPOSRORY OR RECEIPTS FOR HAVE DOUBLE CYL- OTHER MfFORMATKNd ON DUTY DEPOSIT ONLY DEPOSffS USED LAST FISCAL YEAR M1DER DOOR LOCKS? YES NO 8:3a- S: °o yES ~~,, ~. x SAFENAULT DOOR TYPE COMBINATION LOCIC,S THM MANUFACTURER LABEL CLASS ROUNO SQUARE OUTER pVNER CHEST DOOR ~ a. BOLTiI SMNA WALL MESSENGER PROTECTION ' PRIVATE MESS GR at OF GUARDS s PER MESSENGER SAFETY CONVEYANCE SATCHEL USED? USED? PRIVATE MESS'GR >s OF GUARDS N PER MESSENGER CONVEYANCE SAFETY SATCHEL • USED? Uc~D? ^ YE5 ^ NO ^ YES ^ NO PREMISES/SAFE PROTECTION ^ YES ^ NO ^ YES ^ NC ALARM TYPE ALARM DESCRIPTION HOLD UP EXTENT OF PROTECTION GRADE ALARM WSTALLED AND SERVICED BY ~ GUARDS WATCHPERSON - LOCAL GONG SAFENAULT PREMISES PREMISES CENTRAL STATION F WATCH RPf~lfST SAFE POLICE CONNECT Pnltiwl 1 2 3 CpINplF1E PERSONS CLOCKHRLY Wm~ KEYS ACCESSIBLE O PENINGS S PROTECTION DON'~SIGPIAL CERTIFIC TE OTHER PROTECTION (Fences Floodli hts etch A NUMBER , g , EXPIRATION DATE' • CCR 4724m (Ed. 03-02) Page 3 of 5 - PRIOR CRIME INSURANCE HISTORY • Has any similar ins ,~an~ to that bei a lied for been ded~ed or canceled in the last three ars? not Missouri) Yes^ N1'~ ~ Pp Ye ( applicable in the state If / ` "Yes" e~la in 2. List all bsses sustained during the past three years, whether reimbursed or not, from Check if non Brie describe each loss and a lain corrective measures on Oat e Amount Amount qmo~ of of Recovered of Loss lAS Loss from Insurance Pending s 3. tf this policy replaces similar crime insurance, list the prior insurer. to (month,day,year) sheet Amount Recovered Type from other than of Insurance mss ~~ D tr none IJ 4. Will this policy supplement a special multl-peril or other package policy!' ff "Yes", name insurer. Yes ^ No (month,day,year) If loss occur!! at other than Head Office, state location Effedve Date Policy No. h is understood that the first premium upon the Policy applied for, and subsequent premiums thereon, are due at the beginning of each premium period, that the Company is entitled to additional p~smiums because of any unusual increase in the number of Employees or ApplicanPs know) t the Applicant agrees to pay atl such premiums P-'m-rpUY. The Empbyees of the Applicant have all, b the best of the edge and beNef, while in the service of the Applicant always performed their respective dudes honestly_ There has never come to its notice or knowledge any information which in the judgment of the Applicant indir~tes that any of the said Empbyees are dishonest. Such knowledge as any officer signing for the Applicant may now have in rasped to his own personal acts or conduct, unknown b the Applicant, is not imputable to the Applicant. FRAUD NOTICES: Prior to signirag this Proposal Form, please review the following statutory fraud notices as they may apply to the Company's domicile: ARKANSAS: Any person who knowingly presents a false or fraudulent calm for payment of a loss benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information b a policy holder or daimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false -^`~rmation materially related b a daim was provided by the applicant. A: Any person who knowingly and with intent b injure, defraud or deceive any insurer files a statement of cUaim or an application con ng any false, incomplete or misleading statement is guilty of a felony of the third degree. KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing materially false information or conceals for the purpose of misleading, information concerning any fact material ~CR 4724m (Ed. 03-02) Page 4 of 5 ' thereto Commits a fraudulent insurance act, which is a crime. l.0UISIANA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingy presents fags r~ rrnation in an application for insurance is guilty of a aims and may be subject to fines and confinement in prison. AINE: ft is a crime to knowingly provide false, incomplete or misleading infomration to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits, NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and avil penalties. NE1N MEXICO: Any person who knowingly presents a false or fraudulent claim for payment of a bss or benefit or knowingty presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NEW YORK Any person who knowingly and with intent b defraud any insurance comparry or other person files an application for insurance or statement of claim containing materialy false information or cxtnceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance acct. which is a crime, and shah also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the Uaim for each such violation. OHIO: Any person who, with intent bo defraud or knowing tlrat he is facilitating a fraud against an insurer, submits an application or fetes claim containing a false or deceptive statement is guilty ~ insurance fraud. OKLAHOMA: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of a insurance policy, containing false. incomplete or misleading information is guilty of a felony. PENNSYLVANIA: Any person who knowingly and with intent 1o defraud any insurance company or other person files an application for insurance or statement of claim containirg mafsrialy false infom~ation or conceals for the purpose of misleaGng, information concerning any fact material thereto, commits a fraudulent insurance ad, which is a aims and subjects such person to criminal and dvrl penalties. TENNESSEE: ft is a crime to knowingty Provide false, incomplete or misleading in/orrrtation to an insurance company for the Purpose of defrauding the company. Penalties include &nprisonment, fines and denial of insurance benefits. VIRGINIA It is a aims to knowingly provide false, incomplete or misleading information b an insurance company for the purpose o defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Dat this day of I ~_ T~'~d1~ ST.~- . FL.sR r D/A ,ti YT7~ .SFP'I~A'IB 6r'R (Insured) (FL 8 IA Onty) licensed Agent or Broker [7 SCR 4724m (Ed. 03-02) (Name and Title) t~(, c~ r ~j Page 5 of 5 (FL Only) license Number ~Z ~ ~~ r"L___