FY2003 02/19/2003
GRANT OF FUNDS
This AGREEMENT dated the /1 t1ay of z:c.-J3: 2003, is entered into by and between
the BOARD OF COUNTY COMMISSIONERS FOR MONROE COUNTY, hereinafter "County," on
behalf of the TOURIST DEVELOPMENT COUNCIL, hereinafter "TDC," and Mote Marine
Laboratory, a Florida not-for-profit corporation, hereinafter" Contractor".
WHEREAS, the third penny of Tourist Development Tax may be used to acquire, construct,
extend, enlarge, remodel, repair or improve, convention centers, sports stadiums, sports arenas,
coliseums, auditoriums, fishing piers, museums, zoological parks, nature centers and beaches
which are publicly owned and operated or owned and operated by not-for-profit corporations, and
WHEREAS, Contractor has applied for funding for the Key West Facility Access and
Enhancement project to construct, extend, enlarge, remodel and improve the Mote Marine
Laboratory in Key West, hereinafter "the Property"; and
WHEREAS, the County and TDC have determined that it is in the best interest of the
County, for purposes of promoting tourism and preserving the heritage of the community, to
construct, extend, enlarge and remodel and improve the property for use as a nature center open
to the public;
NOW, THEREFORE, in consideration of the mutual covenants and payments contained
herein, the Contractor and the County have entered into this agreement on the terms and
conditions as set forth below.
1. AGREEMENT PERIOD. This agreement is for the period February 19, 2003, through
September 30, 2003. This agreement shall remain in effect for the stated period unless one party
gives to the other written notification of termination pursuant to and in compliance with paragraphs
7,12 and 13 below.
2. SCOPE OF AGREEMENT. The Contractor shall provide such services and materials as are
required for the installation of new doors and entryway weather/shade awning; new aquaria
(snook, coral & 'upsidedown' jellyfish) and descriptive graphics.
The recipient of TDC capital project funding shall designate a project manager if no licensed
architect, engineer or general contractor is involved in the project. If the project is performed by
County or City personnel, the project manager shall be the Engineer, Building Official or
Construction Manager of that local government.
3. AMOUNT OF AGREEMENT AND PAYMENT. The County shall provide an amount not to
exceed $10,000 in reimbursement for materials and services used to acquire, improve,
rehabilitate, repair and renovate the property. The Board of County Commissioners and the
Tourist Development Council assume no liability to fund this agreement for an amount in excess
of this award. Monroe County's performance and obligation to pay under this agreement is
contingent upon an annual appropriation by the BOCC.
a). Payment for expenditures permissible by law and County policies shall be made
through reimbursement to Contractor upon presentation of invoices, canceled checks and other
documentation necessary to support a claim for reimbursement. Included in said documentation
shall be proof that the Contractor has received and applied to the property matching funds
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FY 2003 Capital Project Resources
equivalent to or greater than the amount invoiced to the County. Submission of invoices must be
certified through a statement signed by an officer of the organization and notarized, declaring that
representations in the invoice are true and factual.
b) Application of matching funds requires actual payment of the matching funds, or, in
the alternative, a commitment of said funds and that the portion of the project for which the
matching funds are to be used has been sufficiently completed to require payment of said
matching funds. Mere obligation through execution of a contract or approval of a budget item to
be paid from matching funds will not suffice.
c) Documentation shall be submitted to the TDC Administrative Office to show the
receipt and application of in-kind donations of goods, professional seNices, and materials. Said
documentation should include invoices, bills of lading, etc., and be verified as received and
applied to the project through a notarized statement of the project architect, engineer, general
contractor or project manager. The receipt and application to the project of volunteer labor are to
be documented and verified by notarized signature of the project architect, engineer, general
contractor or project manager, and said documentation submitted to the TDC Administrative
Office. All submissions should have a proposed schedule of values for phases and indicate the
percentage of completion of the overall project as of the submission. This document should be
signed by the project architect, engineer, general contractor or project manager.
4. REPORTS. The Contractor shall provide financial reports in summary of activity on forms
provided or approved by the TDC, and quarterly narrative reports of activity under the approved
work plan. The Contractor shall keep such records as are necessary to document the
performance of the agreement and expenses as incurred, and give access to these records at the
request of the TDC, the County, the State of Florida or authorized agents and representatives of
said government bodies. It is the responsibility of the Contractor to maintain appropriate records
to insure a proper accounting of all funds and expenditures. The Contractor understands that it
shall be responsible for repayment of any and all audit exceptions which are identified by the
Auditor General for the State of Florida, the Clerk of Court for Monroe County, the Board of
County Commissioners for Monroe County, or their agents and representatives. In the event of an
audit exception, the current fiscal year grant award or subsequent grant awards will be offset by
the amount of the audit exception. In the event the grant is not renewed or supplemented in future
years, the Contractor will be billed by the County for the amount of the audit exception and shall
promptly repay any audit exception.
5. MODIFICATIONS AND AMENDMENTS. Any and all modifications of the terms of this
agreement shall be only amended in writing and approved by the Board of County Commissioners
for Monroe County.
6. INDEPENDENT CONTRACTOR. At all times and for all purposes hereunder, the
Contractor is an independent contractor and not an employee of the Board of County
Commissioners of Monroe County. No statement contained in this agreement shall be construed
as to find the Contractor or any of its employees, contractors, seNants or agents to the employees
of the Board of County Commissioners of Monroe County, and they shall be entitled to none of the
rights, privileges or benefits of employees of Monroe County.
7. COMPLIANCE WITH LAW. In carrying out its obligations under this agreement, the
Contractor shall abide by all statutes, ordinances, rules and regulations pertaining to or regulating
the provisions of this agreement, including those now in effect and hereafter adopted. Any
violation of said statutes, ordinances, rules or regulations shall constitute a material breach of this
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agreement and shall entitle the County to terminate this agreement immediately upon delivery of
written notice of termination to the Contractor.
8. RESTRICTIONS ON AGREEMENTS ENTERED PURSUANT TO THIS AGREEMENT. The
Contractor shall include in all agreements funded under this agreement the following terms:
a) Anti-discrimination. Contractor agrees that they will not discriminate against any
employees or applicants for employment or against persons for any other benefit or service under
this agreement because of their race, color, religion, sex, national origin, or physical or mental
handicap where the handicap does not affect the ability of an individual to perform in a position of
employment, and to abide by all federal and state laws regarding non-discrimination.
b) Anti-kickback. Contractor warrants that no person has been employed or retained to
solicit or secure this agreement upon an agreement or understanding for a commission,
percentage, brokerage or contingent fee, and that no employee or officer of the Contractor has
any interest, financially or otherwise, in Contractor. For breach or violation of this warranty, the
Contractor shall have the right to annul this agreement without liability or, in its discretion, to
deduct from the agreement price or consideration, the full amount of such commission,
percentage, brokerage or contingent fee. Contractor acknowledges that it is aware that funding
for this agreement is available at least in part through the County and that violation of this
paragraph may result in the County withdrawing funding for the Project.
c) Hold harmless/indemnification. Contractor acknowledges that this agreement is funded
at least in part by the County and agrees to indemnify and hold harmless the County and any of its
officers and employees from and against any and all claims, liabilities, litigation, causes of action,
damages, costs, expenses (including but not limited to fees and expenses arising from any factual
investigation, discovery or preparation for litigation), and the payment of any and all of the
foregoing or any demands, settlements or judgments (collectively claims) arising directly or
indirectly from any negligence or criminal conduct on the part of Contractor in the performance of
the terms of this agreement. The Contractor shall immediately give notice to the County of any
suit, claim or action made against the Contractor that is related to the activity under this
agreement, and will cooperate with the County in the investigation arising as a result of any suit,
action or claim related this agreement.
d) Insurance. Contractor agrees that it maintains in force at its own expense a liability
insurance policy which will insure and indemnify the Contractor and the County from any suits,
claims or actions brought by any person or persons and from all costs and expenses of litigation
brought against the Contractor for such injuries to persons or damage to property occurring during
the agreement or thereafter that results from performance by Contractor of the obligations set
forth in this agreement. At all times during the term of this agreement and for one year after
acceptance of the project, Contractor shall maintain on file with the County a certificate of the
insurance of the carriers showing that the aforesaid insurance policy is in effect. The following
coverage's shall be provided:
1. Workers Compensation insurance as required by Florida Statutes.
2. Employer's Liability insurance with minimum limits of (aggregate): $100,000 bodily
injury by accident, $500,000 bodily injury by disease aggregate, $100,000 bodily injury by disease
per person.
3. Commercial General Liability Insurance with minimum limits of $500,000 per occurrence
for bodily injury, personal injury and property damage.
4. Comprehensive Auto Liability Insurance with minimum limits of $300,000 combined
single limit per occurrence.
The Contractor, the County and the TDC shall be named as additional insured, exempt workers
compensation. The policies shall provide no less than 30 days notice of cancellation, non-renewal
or reduction of coverage.
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At all times during the term of this agreement and for one year after acceptance of the project,
Contractor shall maintain on file with the County a certificate of insurance showing that the
aforesaid insurance coverage's are in effect.
e) Licensing and Permits. Contractor warrants that it shall have, prior to commencement of
work under this agreement and at all times during said work, all required licenses and permits
whether federal, state, County or City.
9. HOLD HARMLESS/INDEMNIFICATION. The Contractor hereby agrees to indemnify and
hold harmless the BOCCITDC and any of its officers and employees from and against any and all
claims, liabilities, litigation, causes of action, damages, costs, expenses (including but not limited
to fees and expenses arising from any factual investigation, discovery or preparation for litigation),
and the payment of any and all of the foregoing or any demands, settlements or judgments arising
directly or indirectly under this agreement. The Contractor shall immediately give notice to the
County of any suit, claim or action made against the County that is related to the activity under this
agreement, and will cooperate with the County in the investigation arising as a result of any suit,
action or claim related to this agreement.
1 O. ANTI-DISCRIMINATION. The Contractor agrees that they will not discriminate against
any of their employees or applicants for employment or against persons for any benefit or service
because of their race, color, religion, sex, national origin, or physical or mental handicap where
the handicap does not affect the ability of an individual to perform in a position of employment,
and to abide by all federal and state laws regarding non-discrimination.
11. ANTI-KICKBACK. The Contractor warrants that no person has been employed or retained
to solicit or secure this agreement upon an agreement or understanding for a commission,
percentage, brokerage or contingent fee, and that no employee or officer of the County or TDC
has any interest, financially or otherwise, in the said funded project, except for general
membership. For breach or violation of this warranty, the County shall have the right to annul this
agreement without liability or, in its discretion, to deduct from the agreement price or
consideration, the full amount of such commission, percentage, brokerage or contingent fee.
12. TERMINATION. This agreement shall terminate on September 30, 2003. Termination
prior thereto shall occur whenever funds cannot be obtained or cannot be continued at a level
sufficient to allow for the continuation of this agreement pursuant to the terms herein. In the event
that funds cannot be continued at a level sufficient to allow the continuation of this agreement
pursuant to the terms specified herein, this agreement may then be terminated immediately by
written notice of termination delivered in person or by mail to Contractor. The County may
terminate this agreement without cause upon giving written notice of termination to provider. The
County shall not be obligated to pay for any services or goods provided by Contractor after
Contractor has received written notice of termination.
13. TERMINATION FOR BREACH. The County may immediately terminate this agreement
for any breach of the terms contained herein. Such termination shall take place immediately upon
receipt of written notice of said termination. Any waiver of any breach of covenants herein
contained to be kept and performed by Contractor shall not be deemed or considered as a
continuing waiver and shall not operate to bar or prevent the County from declaring a forfeiture for
any succeeding breach either of the same conditions or of any other conditions. Failure to provide
County with certification of use of matching funds or matching in-kind services at or above the rate
of request for reimbursement or payment by is a breach of agreement, for which the County may
terminate this agreement upon giving written notification of termination.
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14. ENTIRE AGREEMENT. This agreement constitutes the entire agreement of the parties
hereto with respect to the subject matter hereof and supersedes any and all prior agreements with
respect to such subject matter between the Contractor and the County.
15. CONSENT TO JURISDICTION. This agreement, its performance, and all disputes arising
hereunder, shall be governed by the laws of the State of Florida, and both parties agree that the
proper venue for any actions shall be in Monroe County.
16. ETHICS CLAUSE: Contractor warrants that he has not employed, retained or otherwise
had act on his behalf any former County officer or employee in violation of Section 2 or Ordinance
No. 10-1990 or any County officer or employee in violation of Section 3 of Ordinance No. 10-1990.
For breach or violation of the provision the County may, at its discretion terminate this agreement
without liability and may also, at its discretion, deduct from the agreement or purchase price, or
otherwise recover, the full amount of any fee, commission, percentage, gift, or consideration paid
to the former or present County officer or employee.
17. PUBLIC ENTITY CRIME STATEMENT: A person or affiliate who has been placed on the
convicted vendor list following a conviction for public entity crime may not submit a bid on an
agreement to provide any goods or services to a public entity, may not submit a bid on a
agreement with a public entity for the construction or repair of a public building or public work, may
not submit bids on leases of real property to public entity, may not be awarded or perform work as
a Contractor, supplier, sub-contractor, or consultant under a agreement with any public entity, and
may not transact business with any public entity in excess of the threshold amount provided in
Section 287.017, for CATEGORY TWO for a period of 36 months from the date of being placed on
the convicted vendor list.
18. AUTHORITY: Contractor warrants that it is authorized by law to engage in the
performance of the activities encompassed by the project herein described. Each of the
signatories for the Contractor below certifies and warrants that the Contractor's name in this
agreement is the full name as designated in its corporate charter (if a corporation); they are
empowered to act and contract for the Contractor, and this agreement has been approved by the
Board of Directors of Contractor or other appropriate authority.
19. LICENSING AND PERMITS: Contractor warrants that it shall have, prior to commencement
of work under this agreement and at all times during said work, all required licenses and permits
whether federal, state, County or City.
20. INSURANCE: Contractor agrees that it maintains in force at its own expense a liability
insurance policy which will insure and indemnify the Contractor and the County from any suits,
claims or actions brought by any person or persons and from all costs and expenses of litigation
brought against the Contractor for such injuries to persons or damage to property occurring during
the agreement or thereafter that results from performance by Contractor of the obligations set
forth in this agreement. At all times during the term of this agreement and for one year after
acceptance of the project, Contractor shall maintain on file with the County a certificate of the
insurance of the carriers showing that the aforesaid insurance policy is in effect. The following
coverage's shall be provided:
1. Workers Compensation insurance as required by Florida Statutes.
Mote Marine Laboratories: Key West
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2. Employer's Liability insurance with minimum limits of (aggregate): $100,000 bodily
injury by accident, $500,000 bodily injury by disease aggregate, $100,000 bodily injury by disease
per person.
3. Commercial General Liability Insurance with minimum limits of $500,000 per occurrence
for bodily injury, personal injury and property damage.
4. Comprehensive Auto Liability Insurance with minimum limits of $300,000 combined
single limit per occurrence.
The Contractor, the County and the TDC shall be named as additional insured, except workers
compensation. The policies shall provide no less than 30 days notice of cancellation, non-renewal
or reduction of coverage.
At all times during the term of this agreement and for one year after acceptance of the project,
Contractor shall maintain on file with the County a certificate of insurance showing that the
aforesaid insurance coverage's are in effect.
21. NOTICE. Any written notice to be given to either party under this agreement or related
hereto shall be addressed and delivered as follows:
For Mote Marine Laboratory:
Pete Braisted
24244 Overseas Hwy
Summerland Key, FL 33042
For County:
Lynda Stuart
Monroe County Tourist Development Council
1201 White Street, Suite 102
Key West, FL 33040
and
Suzanne Hutton, Asst. County Attorney
P.O. Box 1026
Key West, FL 33041-1026
IN WITNESS WHEREOF, the parties hereto have caused this agreement to be executed
the day and year first above written.
(SEAL)
ATTEST: DANNYL. KOLHAGE,CLERK
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
By:
"pia >n ~
By:
Mayor/Chairman
(SEAL)
ATTEST:
By:
By: De(~ C;~'41\
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Mote Marine Laboratories: Key West
FY 2003 Capital Project Resources
ACORD, CERTIFICi OF LIABILITY INSUKANCE 01/Z6/
2003
PRODUCER (941)748-1431 FAX (941)746-8063 IMIS CARLIr14A It 13 ISSUAD AS A MA 1ILK or INFORMATION
Wyman, Green & Blalock, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
YRMHOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
1111 8th Avenue W. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Bradenton, FL 34205 INSURERS AFFORDING COVERAGE
INSURED Mote Marine Laboratory, Inc. INSURER A: International M ' UN
1600 Ken Thompson Pkwy INSURERS: National Trust Insurance Co.
Sarasota, FL 34236 INSURER C: International M ' U/81
INSURERD: F C C I Insurance Conpany
INSURER E:
COVERAGE$
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
R TYPE OF INSURANCE
SYNCE II P NUMBER DATE IMATgYYI P
LTR
DATE IW WAITS
S
TYPE
LIMOS/ IC2JH21265 PSI 01/01/2003 01/01/2004 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY II FIRE DAMAGE(Any ane Ere) S 100,000
^
ICLAIMS MADE OCCUR MED EYE,(Any one Ramon) E 5,000
A ylll PERSONAL&ADV INJURY S 1,000,000
GENERAL AGGREGATE S 2,000,000
GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG S 2,000,000
—I POLICYn Tgi n LOG
AUTOMOBILE LIABILITY CA0000670 03/01/2002 03/01/2003 COMBINED SINGLE UNIT E
X ANY AUTO (E.accident) 1,000,000
ALL OWNED AUTOS BODILY INJURY
B SCHEDULED AUTOS APPd ./ ['BIT R1AN S
X HIRED AUTOS BODILY INJURY
X NOi.OWNE0 AUTOS BY 0 (Pr occident) E
_ " DATE ' (� PROPERTY DAMAGE E
/YES (Per accident)
GOUGE MESSYMESSYwatt' n C4a AUTO ONLY-EAACCIDENT E
R ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG S
EXCESS UABUTY CZ3H21280 01/01/2003 01/01/2004 EACH OCCURRENCE $ 2,000,000
OCCUR n CLAIMS MADE AGGREGATE $ 2,000,000
C E
DEDUCTIBLE E
RETENTION $ E
WORKERS COMPENSATION AND 34570 01/01/2003 01/01/2004 TMYUMIrS I !ER.
CM;:.::EGaa LW.flY
D E.L.EACH ACCIDENT E 1,000R000
E.L.DISEASE-EA EMPLOYEE E 1,000,000
E.L.DISEASE•POUCY LIMIT E 1,000,000
— OTHER CZ]H21265 PSI 01/01/2003 01/01/2004 S1,000,000 Occurrence
A Boat Liability S2,000,000 Aggregate
DESC'RWTui OF OPERA,u,is OCA1gNSNEHI:LENEXCWBIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
7.ertificate Holder is shown as Additional Insured
CERTIFICATE HOLDER I X ADDITIONAL INSURED;INSURER LETTER - CANCELLATION
SHOULD ANY OF THE ABOVE GESCRBEO POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF.THE ISSUING COMPANY WILLENDEAYOR TO MAIL
Monroe County - Board of County Commissioners %0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER HAMED TO THE LEFT,
and Tourist Developmental Council BUT FAILUP£TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATOR OR LIABILITY
1100 Simonton Street OF ANY mna UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
Key West, FL 33040 AUTHORIZED REPRESENTATIVE
Corky Taylor AAI/mK
LLj c- 'st..74,,
ACUHu 2641 InaY) ®AGUHU CORPORA RUN 1888
2003 IVVT-FUH-F'KVF11- %;Utit'VRATIVIV zs-
UNIFORM BUSINE' ► REPORT (UBR) P
DOCUMENT # 713693 '„•, '
1. Entity Name ti . 4.tf• .
MOTE MARINE LABORATORY, INC. ' • - -' �'
Principal Place of Business Mailing Address
1600 KEN THOMPSON PARKWAY 1E03 KEN THOMPSON PARKWAY
SARASOTA FL 34236 SARASOTA FL 34236
2. Principal Place of Business 3. Mailing Address I ifif IIIII IIIII IIIII I II IIIII l II Ilill lllll IIIII IINI III„IIIII lit
Suite,Apt.#,etc. Suite,Apt.#,etc. ❑ CHECK HERE IF MAKING CHANGES
City&State City&State 4. FEI Number 59.0756643 Applied For
Not Applicable
Zip Country Zip Country $8.75 Additional
5. Certificate of Status Desired Fee Required
•
8. Name and Address of Current Registered Agent 7. Name and Address of New R tared Agent
Name
SMITH, DENA J Street Address(P.O.Box Number is Not Acceptable)
1600 KEN THOMPSON PARKWAY
SARASOTA FL 34236
City FL Zip Code
8. The above named entity submits this statement for the purpose of changing its registered office or registered agent,or both,in the State of Florida. I am familiar with,and accept
the obligations of registered agent. ,
SIGNATURE • ..
Signature,typed or printed name ot registered agent end title it appitcabe. (NOTE:Registered Agent signature required Alen reinstating) DATE
'r *.... ,% ; � '9a, 4 9. Election Campaign Financing $5.00 May Be
t}; rp .}t• l A• 1./' Trust Fund Contribution. ❑ Added to Fees +1 -,
10. OFFICERS AND DIRECTORS 11. ADDITIONS/CHANGES TO OFFICERS AND DIRECTORS IN 10
TITLE AS 0 Delete TITLE 0 Change ❑Addition i
NAME SMITH,DENA J NIME ,
STREET ADDRESS 1600 KEN THOMPSON PARKWAY STREET ADDRESS r
CITY-ST-ZIP SARASOTA FL 34236 CITY-sr-ZIP i
TITLE CT ❑Delete TIRE T/v5tt°G gChange ❑Addition
NAME DERR, FREDERICK M NMAE
STREET ADDRESS 1600 KEN THOMPSON PKWY STREET ADDRESS
CITY-sT-ZIP SARASOTA FL 34236 CITY-ST-ZIP
TITLE ST r� ❑Delete TIRE hange ❑Addition
NAME LANG, ROBERT NAME
STREET ADDRESS 2443 PINE ISLAND ROAD STREET ADDRESS but, (wet
CITY-ST-ZIP LONGBOAT KEY FL 34228 CITY-ST-ZIP 1 ' ., .(- Q
TITLE VCT ❑Delete TITLE CHA/R�'I'IgN KChange ❑Addition
NAME MONFORT, MYRA NAME
STREET ADDRESS 601 PUTTER LANE STREET ADDRESS ;.n,`
CITY-ST-ZIP CAPE CORAL ZIP kDt FL 34228 CITY-ST- t11 ►V I it 34-222
TITLE ED ❑Delete TITLE ❑Change ❑Addition
NAME MAHADEVAN, S. NAME '
STREET ADDRESS 1600 THOMPSON PARKWAY STREET ADDRESS
CITY-ST-ZIP SARASOTA FL CITY-ST-ZIP
TITLE ❑Delete TITLE ❑Change ❑Addition
NAME NAME
STREET ADDRESS STREET ADDRESS
CITY-ST-ZIP CITY-ST-ZIP
12. I hereby certify that the information s •plied with this filing does not qualify for the exemption stated in Section 119.07(3)(i),Florida Statutes.I further certify that the information
indicated on this report or supple r: at report is true and accurate and that my signature shall have the same legal effect as If made under oath;that I am an officer or director
of the corporation or the receiver stee empower:.to execute this report as required by Chapter 617,Florida Statutes;and that my name appears In Block 10 or Block 11 if
changed,or on an attachment, ddress,wit f I other like empowered.
SIGNATURE: 41. . �i' �i 0�' _ • UIRED '1'1-d3
.:Tr runs Norm)•tlNAM7 •NA Or SIONINO OFFICER OR DIRECTOR Date T
AN °Wara Prone e
., ..:•ht.•.V}!Y:ai,011f/'fX•,r+r•�ar�•vr.p1.,_..:n... ..M. ... .,'rn.),:•t:Y.'Y••••:.":..+�.+'. .+trr:. .•rp,••v t.. . -},;- .. ... .!:'trM1/z".. ,