13-000580RU Beachlen Development Company, Llc vs. Department Of Business And Professional Regulation And Florida Building Commission Status: Closed Settled and/or Dismissed prior to entry of RO/FO on Friday, April 12, 2013.

Certificate of Good Faith E ffort to Resolve Dispute,

Acknowledgement of Fraud Statement, Certificate of Service, and Social Security Number Notice

The claimant or, if the claimant is re presented by counsel, the claimant's a ttorney, certifies that he or she has

made a good faith effort to resolve th e dispute and that the claimant or attorney was unable to resolve the

dispute with the employer/ca rrier/servicing agent.

The claimant has read and understands the following: "Any person who, knowingly and with intent to injure,

defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of

claim containing any false or misleading information co mmits insurance fraud, punishable as provided in s.

817.234." By signing below, the claimant attests that he or she has reviewed, understands, and acknowledges

the foregoing notice. In accordance with Florida Statut es § 440.192(1), a copy of this petition for benefits has

been served by certified mail on the injured work er’s employer and the employer’s carrier on ______________.

A copy of this petition has also been served on the attorney for the employer/carrier if known.

Disclosure of the employee’s Social Security Number (SSN) is voluntary. An employee or claimant who does

not have or declines to provide the employee’s SSN mu st file a verified motion for assignment of substitute

identification number along with the init ial Petition for Benefits or Request for Assignment of Case Number in

accordance with Fla. Admin. Code 60Q-6.105(4).

The employee’s SSN will be used to uniquely iden tify the employee in the Office of the Judges of

Compensation Claims (OJCC) case management system, as certain a claimant’s child support obligations before

approving any lump sum settlement, and exchange inform ation between the OJCC and the Division of Workers’

Compensation. The employee’s SSN may also be used by the employer and carrier named on the Petition for

Benefits or Request for Assignment of Ca se Number to identify the employee.

SSN’s are confidential and exempt from public disclosure. It is the expr ess policy of the OJCC to prohibit the

disclosure of SSN’s by the OJCC or any of its employees, except the SSN will be disclosed by the OJCC for the

following reasons: (1) in res ponse to a legitimate inquiry from a state or federal agency in connection with

matters within its jurisdiction; (2) if so ordered by a court of competent jurisdiction, pursuant to the terms of

such order; and (3) to a commercial entity in re sponse to a request in accordance with §119.071(5)(a)(7),

Florida Statutes.

WHEREFORE, claimant requests an order directing th e employer to provide the benefits as requested.

_____________________________________ _____________________________________

Signature of Claimant Date Signature of Counsel for Claimant Date

OJCC Form PFBSIG (Revised 1-9-2008)