Preview
IN THE CIRCUIT COURT FOR THE TWENTIETH JUDICIAL CIRCUIT
IN AND FOR CHARLOTTE COUNTY, FLORIDA
CIRCUIT CIVIL DIVISION
BARBARA GONZALEZ,
CASE NO.: 21000968CA
Plaintiff,
MICHAEL G. EDWARDS and HHS
ENVIRONMENTAL SERVICES, LLC
Defendants.
NOTICE OF PRODUCTION FROM NON-PARTY
YOU ARE HEREBY NOTIFIED that after ten (10) days of service of this Notice of
Production from Non-Party, the undersigned will apply to the Clerk of the Court for issuance of
the attached Subpoenas directed to:
1. Bayfront Health
2. Gallagher Bassett
3. Brian Bartley, Esq.
4. Michael J. Winer, Esq.
5. Division of Worker’s Compensation (Updated records)
who are not a party to this action, to produce the items listed at the time and place
specified in the Subpoena.
CERTIFICATE OF SERVICE
WE HEREBY CERTIFY that a true and correct copy of the foregoing was e-mailed to all
counsel of the attached Service List this 16th day of March, 2023.
KUBICKI DRAPER
9100 South Dadeland Blvd.
Suite 1800
Miami, FL 33156
Kubicki Draper • 9100 S. Dadeland Boulevard, Suite 1800, Miami, Florida 33156 • T: (305) 374-1212 • F: (305) 374-7846
Telephone: (305) 982-6604
Facsimile: (305) 374-7846
Pleadings:
By: /s/ Francesca Ippolito-Craven
FRANCESCA IPPOLITO-CRAVEN
Florida Bar Number: 0145361
SERVICE LIST
Co-counsel for Plaintiff:
Michael J. Rossi, Esq.
MICHAEL J. ROSSI, P.A.
Tampa, FL 33606
michael@michaelrossilaw.com
STRATIGAKOS LAW, P.A.
Tampa, FL 33602
marty@stratigakoslaw.com
Kubicki Draper • 9100 S. Dadeland Boulevard, Suite 1800, Miami, Florida 33156 • T: (305) 374-1212 • F: (305) 374-7846
IN THE CIRCUIT COURT FOR THE
TWENTIETH JUDICIAL CIRCUIT
IN AND FOR CHARLOTTE COUNTY,
CIRCUIT CIVIL DIVISION
BARBARA GONZALEZ,
CASE NO.: 21000968CA
Plaintiff,
MICHAEL G. EDWARDS and HHS
ENVIRONMENTAL SERVICES, LLC
Defendants.
SUBPOENA DUCES TECUM FOR THE PRODUCTION OF DOCUMENTS
AND THINGS WITHOUT DEPOSITIONS
Bayfront Health Port Charlotte d/b/a Shorepoint Health Port Charlotte
Legal Division
2500 Harbor Blvd.
Port Charlotte, FL 33952
YOU ARE HEREBY COMMANDED to produce
Francesca Ippolito-Craven, Esquire, at KUBICKI DRAPER, 9100 S. Dadeland Blvd., Suite
1800, in Miami, Florida 33156, within TEN (10) days of service of this Subpoena, copies of the
Barbara Gonzalez; D.O.B: SS#:
xxx-xx- Claim Number: 5910S816K; Policy
Bayfront Health of Port Charlotte, 2500 Harbor Blvd, Port Charlotte, FL 33952 on July 7,
2020 that is the subject of Barbara Gonzalez v. Bayfront Health of Port Charlotte and
Gallagher Bassett, Worker’s Compensation Case Number: 21-012902JAW
• All pleadings
• All discovery and responses to same
• All agreements between Gonzalez and the hospital
• All agreements between Gonzalez and the WC insurer
• All releases and/or hold harmless agreements between Gonzalez and the hospital
• All releases and/or hold harmless agreements between Gonzalez and the WC
Insurer
• All deposition transcripts taken in the WC matter
• All written, recorded and/or transcribed statements concerning the incident
• All incidents reports concerning the incident
• All medical records pertaining to Gonzalez
• All radiographic images pertaining to Gonzalez
• All medical expenses pertaining to Gonzalez
• All independent and/or compulsory medical examination reports
• All records evidencing payments toward medical expenses
• All employment records
• All records evidencing payments towards loss of past and future wages
• All records evidencing payment of WC benefits
You have the right to make a legal objection to the production of these materials under
If you fail to comply, you may be
You may request reasonable costs for preparing these documents in advance by making
A copy of this Subpoena has been furnished to all counsel of record. Also, please
complete, sign, and notarize the attached affidavit.
COMPLIANCE WITH HIPAA DISCLOSURE
Defendant has complied with 45 C.F.R., Section 164.512(e) and Rule 1.351 of the
Undersigned certifies that:
1) Written notice has been provided to the insurance and/or the individual’s attorney for
whom the documents are sought,
2) The notice included sufficient information about the litigation and/or proceeding to
permit the individual or his/her attorney to raise an objection to the production of the requested
documents,
3) The time to raise an objection has elapsed and,
4) Neither the individual nor his/her attorney filed an objection to the above-listed
WITNESS my hand and seal on March 27, 2023.
FRANCESCA A. IPPOLITO-CRAVEN
For the Court
/s/ Francesca Ippolito-Craven
Florida Bar Number 0145361
Francesca Ippolito-Craven, Esquire
KUBICKI DRAPER
9100 S. Dadeland Blvd., Suite 1800
Miami, FL 33156
Telephone: (305) 982-6604
Facsimile: (305) 374-7846
If you are a person with a disability who needs any accommodation in order to respond to this
subpoena, you are entitled, at no cost to you, to the provision of certain assistance. Please contact
FRANCESCA IPPOLITO-CRAVEN of Kubicki Draper at (305) 982-6737 at least 7 days before
your scheduled appearance, or immediately upon receiving this notification if the time before the
scheduled appearance is less than 7 days; if you are hearing or voice impaired, call 711.
For questions regarding this Subpoena
Please contact Nicole Almeida (305) 982-6754
FEDERAL RULE OF EVIDENCE 902 CERTIFICATION/DECLARATION OF
RECORDS CUSTODIAN
In accordance with Federal Rule of Evidence 902 Self-Authentication, I
___________________, Custodian of Records, do hereby produce the attached records of
Barbara Gonzalez; DOB: and do hereby certify that such records:
Were made at or near the time of the occurrence of the matters set forth by, or from
information transmitted by a person or persons with knowledge of the matters,
acting within the course of the regularly conducted business activity;
b) Were kept in the course of the regularly conducted business activity;
c) Were made as a regular practice in the course of the regularly conducted activity;
d) And are true and accurate copies of the original records.
I have read every statement made in this certification, and each statement is true and
correct. I understand that falsely making such a certification or declaration would subject
me to criminal penalty under the laws of the foreign or domestic location in which the
certification or declaration was signed.
Records Custodian’s Signature Date
Sworn to or affirmed and signed before me on this _____ day of ___________________,
Notary Public
My commission expires:
IN THE CIRCUIT COURT FOR THE
TWENTIETH JUDICIAL CIRCUIT
IN AND FOR CHARLOTTE COUNTY,
CIRCUIT CIVIL DIVISION
BARBARA GONZALEZ,
CASE NO.: 21000968CA
Plaintiff,
MICHAEL G. EDWARDS and HHS
ENVIRONMENTAL SERVICES, LLC
Defendants.
SUBPOENA DUCES TECUM FOR THE PRODUCTION OF DOCUMENTS
AND THINGS WITHOUT DEPOSITIONS
TO: Gallagher Bassett Services Inc.
The Prentice Hall Corporation System, Inc.
1201 Hays Street
Tallahassee, FL 32301
YOU ARE HEREBY COMMANDED to produce without deposition and deliver to
Francesca Ippolito-Craven, Esquire, at KUBICKI DRAPER, 9100 S. Dadeland Blvd., Suite
1800, in Miami, Florida 33156, within TEN (10) days of service of this Subpoena, copies of the
following as it pertains to the incident involving Barbara Gonzalez; D.O.B: SS#:
xxx-xx- Claim Number: 5910S816K; Policy Number: D41837259C; that happened at
Bayfront Health of Port Charlotte, 2500 Harbor Blvd, Port Charlotte, FL 33952 on July 7,
2020 that is the subject of Barbara Gonzalez v. Bayfront Health of Port Charlotte and
Gallagher Bassett, Worker’s Compensation Case Number: 21-012902JAW
• All pleadings
• All discovery and responses to same
• All agreements between Gonzalez and the hospital
• All agreements between Gonzalez and the WC insurer
• All releases and/or hold harmless agreements between Gonzalez and the hospital
• All releases and/or hold harmless agreements between Gonzalez and the WC
Insurer
• All deposition transcripts taken in the WC matter
• All written, recorded and/or transcribed statements concerning the incident
• All incidents reports concerning the incident
• All medical records pertaining to Gonzalez
• All radiographic images pertaining to Gonzalez
• All medical expenses pertaining to Gonzalez
• All independent and/or compulsory medical examination reports
• All records evidencing payments toward medical expenses
• All employment records
• All records evidencing payments towards loss of past and future wages
• All records evidencing payment of WC benefits
You have the right to make a legal objection to the production of these materials under
If you fail to comply, you may be
You may request reasonable costs for preparing these documents in advance by making
A copy of this Subpoena has been furnished to all counsel of record. Also, please
complete, sign, and notarize the attached affidavit.
COMPLIANCE WITH HIPAA DISCLOSURE
Defendant has complied with 45 C.F.R., Section 164.512(e) and Rule 1.351 of the
Undersigned certifies that:
1) Written notice has been provided to the insurance and/or the individual’s attorney for
whom the documents are sought,
2) The notice included sufficient information about the litigation and/or proceeding to
permit the individual or his/her attorney to raise an objection to the production of the requested
documents,
3) The time to raise an objection has elapsed and,
4) Neither the individual nor his/her attorney filed an objection to the above-listed
WITNESS my hand and seal on March 27, 2023.
FRANCESCA A. IPPOLITO-CRAVEN
For the Court
/s/ Francesca Ippolito-Craven
Florida Bar Number 0145361
Francesca Ippolito-Craven, Esquire
KUBICKI DRAPER
9100 S. Dadeland Blvd., Suite 1800
Miami, FL 33156
Telephone: (305) 982-6604
Facsimile: (305) 374-7846
If you are a person with a disability who needs any accommodation in order to respond to this
subpoena, you are entitled, at no cost to you, to the provision of certain assistance. Please contact
FRANCESCA IPPOLITO-CRAVEN of Kubicki Draper at (305) 982-6737 at least 7 days before
your scheduled appearance, or immediately upon receiving this notification if the time before the
scheduled appearance is less than 7 days; if you are hearing or voice impaired, call 711.
For questions regarding this Subpoena
Please contact Nicole Almeida (305) 982-6754
FEDERAL RULE OF EVIDENCE 902 CERTIFICATION/DECLARATION OF
RECORDS CUSTODIAN
In accordance with Federal Rule of Evidence 902 Self-Authentication, I
___________________, Custodian of Records, do hereby produce the attached records of
Barbara Gonzalez; DOB: and do hereby certify that such records:
Were made at or near the time of the occurrence of the matters set forth by, or from
information transmitted by a person or persons with knowledge of the matters,
acting within the course of the regularly conducted business activity;
b) Were kept in the course of the regularly conducted business activity;
c) Were made as a regular practice in the course of the regularly conducted activity;
d) And are true and accurate copies of the original records.
I have read every statement made in this certification, and each statement is true and
correct. I understand that falsely making such a certification or declaration would subject
me to criminal penalty under the laws of the foreign or domestic location in which the
certification or declaration was signed.
Records Custodian’s Signature Date
Sworn to or affirmed and signed before me on this _____ day of ___________________,
Notary Public
My commission expires:
IN THE CIRCUIT COURT FOR THE
TWENTIETH JUDICIAL CIRCUIT
IN AND FOR CHARLOTTE COUNTY,
CIRCUIT CIVIL DIVISION
BARBARA GONZALEZ,
CASE NO.: 21000968CA
Plaintiff,
MICHAEL G. EDWARDS and HHS
ENVIRONMENTAL SERVICES, LLC
Defendants.
SUBPOENA DUCES TECUM FOR THE PRODUCTION OF DOCUMENTS
AND THINGS WITHOUT DEPOSITIONS
Brian S. Bartley , Esquire
The Chartwell Law Offices, LLP
12486 Brantley Commons Ct
Fort Myers, FL 33907-5663
YOU ARE HEREBY COMMANDED to produce
Francesca Ippolito-Craven, Esquire, at KUBICKI DRAPER, 9100 S. Dadeland Blvd., Suite
1800, in Miami, Florida 33156, within TEN (10) days of service of this Subpoena, copies of the
Barbara Gonzalez; D.O.B: SS#:
xxx-xx- that happened at Bayfront Health of Port Charlotte, 2500 Harbor Blvd, Port
Charlotte, FL 33952 on July 7, 2020 that is the subject of Barbara Gonzalez v. Bayfront
Health of Port Charlotte and Gallagher Bassett, Worker’s Compensation Case Number:
• All pleadings
• All discovery and responses to same
• All agreements between Gonzalez and the hospital
• All agreements between Gonzalez and the WC insurer
• All releases and/or hold harmless agreements between Gonzalez and the hospital
• All releases and/or hold harmless agreements between Gonzalez and the WC
Insurer
• All deposition transcripts taken in the WC matter
• All written, recorded and/or transcribed statements concerning the incident
• All incidents reports concerning the incident
• All medical records pertaining to Gonzalez
• All radiographic images pertaining to Gonzalez
• All medical expenses pertaining to Gonzalez
• All independent and/or compulsory medical examination reports
• All records evidencing payments toward medical expenses
• All employment records
• All records evidencing payments towards loss of past and future wages
• All records evidencing payment of WC benefits
You have the right to make a legal objection to the production of these materials under
If you fail to comply, you may be
You may request reasonable costs for preparing these documents in advance by making
A copy of this Subpoena has been furnished to all counsel of record. Also, please
complete, sign, and notarize the attached affidavit.
COMPLIANCE WITH HIPAA DISCLOSURE
Defendant has complied with 45 C.F.R., Section 164.512(e) and Rule 1.351 of the
Undersigned certifies that:
1) Written notice has been provided to the insurance and/or the individual’s attorney for
whom the documents are sought,
2) The notice included sufficient information about the litigation and/or proceeding to
permit the individual or his/her attorney to raise an objection to the production of the requested
documents,
3) The time to raise an objection has elapsed and,
4) Neither the individual nor his/her attorney filed an objection to the above-listed
WITNESS my hand and seal on March 27, 2023.
FRANCESCA A. IPPOLITO-CRAVEN
For the Court
/s/ Francesca Ippolito-Craven
Florida Bar Number 0145361
Francesca Ippolito-Craven, Esquire
KUBICKI DRAPER
9100 S. Dadeland Blvd., Suite 1800
Miami, FL 33156
Telephone: (305) 982-6604
Facsimile: (305) 374-7846
If you are a person with a disability who needs any accommodation in order to respond to this
subpoena, you are entitled, at no cost to you, to the provision of certain assistance. Please contact
FRANCESCA IPPOLITO-CRAVEN of Kubicki Draper at (305) 982-6737 at least 7 days before
your scheduled appearance, or immediately upon receiving this notification if the time before the
scheduled appearance is less than 7 days; if you are hearing or voice impaired, call 711.
For questions regarding this Subpoena
Please contact Nicole Almeida (305) 982-6754
FEDERAL RULE OF EVIDENCE 902 CERTIFICATION/DECLARATION OF
RECORDS CUSTODIAN
In accordance with Federal Rule of Evidence 902 Self-Authentication, I
___________________, Custodian of Records, do hereby produce the attached records of
Barbara Gonzalez; DOB: and do hereby certify that such records:
Were made at or near the time of the occurrence of the matters set forth by, or from
information transmitted by a person or persons with knowledge of the matters,
acting within the course of the regularly conducted business activity;
b) Were kept in the course of the regularly conducted business activity;
c) Were made as a regular practice in the course of the regularly conducted activity;
d) And are true and accurate copies of the original records.
I have read every statement made in this certification, and each statement is true and
correct. I understand that falsely making such a certification or declaration would subject
me to criminal penalty under the laws of the foreign or domestic location in which the
certification or declaration was signed.
Records Custodian’s Signature Date
Sworn to or affirmed and signed before me on this _____ day of ___________________,
Notary Public
My commission expires:
IN THE CIRCUIT COURT FOR THE
TWENTIETH JUDICIAL CIRCUIT
IN AND FOR CHARLOTTE COUNTY,
CIRCUIT CIVIL DIVISION
BARBARA GONZALEZ,
CASE NO.: 21000968CA
Plaintiff,
MICHAEL G. EDWARDS and HHS
ENVIRONMENTAL SERVICES, LLC
Defendants.
SUBPOENA DUCES TECUM FOR THE PRODUCTION OF DOCUMENTS
AND THINGS WITHOUT DEPOSITIONS
Michael J. Winer
Winer Law Group
110 N. 11th St, 1st Floor
Tampa, FL 33602
YOU ARE HEREBY COMMANDED to produce
Francesca Ippolito-Craven, Esquire, at KUBICKI DRAPER, 9100 S. Dadeland Blvd., Suite
1800, in Miami, Florida 33156, within TEN (10) days of service of this Subpoena, copies of the
Barbara Gonzalez; D.O.B: SS#:
xxx-xx- that happened at Bayfront Health of Port Charlotte, 2500 Harbor Blvd, Port
Charlotte, FL 33952 on July 7, 2020 that is the subject of Barbara Gonzalez v. Bayfront
Health of Port Charlotte and Gallagher Bassett, Worker’s Compensation Case Number:
• All pleadings
• All discovery and responses to same
• All agreements between Gonzalez and the hospital
• All agreements between Gonzalez and the WC insurer
• All releases and/or hold harmless agreements between Gonzalez and the hospital
• All releases and/or hold harmless agreements between Gonzalez and the WC
Insurer
• All deposition transcripts taken in the WC matter
• All written, recorded and/or transcribed statements concerning the incident
• All incidents reports concerning the incident
• All medical records pertaining to Gonzalez
• All radiographic images pertaining to Gonzalez
• All medical expenses pertaining to Gonzalez
• All independent and/or compulsory medical examination reports
• All records evidencing payments toward medical expenses
• All employment records
• All records evidencing payments towards loss of past and future wages
• All records evidencing payment of WC benefits
You have the right to make a legal objection to the production of these materials under
If you fail to comply, you may be
You may request reasonable costs for preparing these documents in advance by making
A copy of this Subpoena has been furnished to all counsel of record. Also, please
complete, sign, and notarize the attached affidavit.
COMPLIANCE WITH HIPAA DISCLOSURE
Defendant has complied with 45 C.F.R., Section 164.512(e) and Rule 1.351 of the
Undersigned certifies that:
1) Written notice has been provided to the insurance and/or the individual’s attorney for
whom the documents are sought,
2) The notice included sufficient information about the litigation and/or proceeding to
permit the individual or his/her attorney to raise an objection to the production of the requested
documents,
3) The time to raise an objection has elapsed and,
4) Neither the individual nor his/her attorney filed an objection to the above-listed
WITNESS my hand and seal on March 27, 2023.
FRANCESCA A. IPPOLITO-CRAVEN
For the Court
/s/ Francesca Ippolito-Craven
Florida Bar Number 0145361
Francesca Ippolito-Craven, Esquire
KUBICKI DRAPER
9100 S. Dadeland Blvd., Suite 1800
Miami, FL 33156
Telephone: (305) 982-6604
Facsimile: (305) 374-7846
If you are a person with a disability who needs any accommodation in order to respond to this
subpoena, you are entitled, at no cost to you, to the provision of certain assistance. Please contact
FRANCESCA IPPOLITO-CRAVEN of Kubicki Draper at (305) 982-6737 at least 7 days before
your scheduled appearance, or immediately upon receiving this notification if the time before the
scheduled appearance is less than 7 days; if you are hearing or voice impaired, call 711.
For questions regarding this Subpoena
Please contact Nicole Almeida (305) 982-6754
FEDERAL RULE OF EVIDENCE 902 CERTIFICATION/DECLARATION OF
RECORDS CUSTODIAN
In accordance with Federal Rule of Evidence 902 Self-Authentication, I
___________________, Custodian of Records, do hereby produce the attached records of
Barbara Gonzalez; DOB: and do hereby certify that such records:
Were made at or near the time of the occurrence of the matters set forth by, or from
information transmitted by a person or persons with knowledge of the matters,
acting within the course of the regularly conducted business activity;
b) Were kept in the course of the regularly conducted business activity;
c) Were made as a regular practice in the course of the regularly conducted activity;
d) And are true and accurate copies of the original records.
I have read every statement made in this certification, and each statement is true and
correct. I understand that falsely making such a certification or declaration would subject
me to criminal penalty under the laws of the foreign or domestic location in which the
certification or declaration was signed.
Records Custodian’s Signature Date
Sworn to or affirmed and signed before me on this _____ day of ___________________,
Notary Public
My commission expires:
IN THE CIRCUIT COURT FOR THE
TWENTIETH JUDICIAL CIRCUIT
IN AND FOR CHARLOTTE COUNTY,
CIRCUIT CIVIL DIVISION
BARBARA GONZALEZ,
CASE NO.: 21000968CA
Plaintiff,
MICHAEL G. EDWARDS and HHS
ENVIRONMENTAL SERVICES, LLC
Defendants.
SUBPOENA DUCES TECUM FOR THE PRODUCTION OF DOCUMENTS
AND THINGS WITHOUT DEPOSITIONS
Division of Workers Compensation
200 East Gaines Street, Room 131
Tallahassee, FL 32399
YOU ARE HEREBY COMMANDED to produce without deposition and deliver to
Francesca Ippolito-Craven, Esquire, at KUBICKI DRAPER, 9100 S. Dadeland Blvd., Suite
1800, in Miami, Florida 33156, within TEN (10) days of service of this Subpoena, copies of the
Plaintiff: Barbara Gonzalez; D.O.B: SS#: xxx-xx-
Any and all WORKERS COMPENSATION records from January 27, 2022-Present
, including but not limited to, all workers compensation records, Notice of Injury
forms, payout sheets, and any and all documentation within your possession, custody
and/or control, including, but not limited to, insurance records, claim forms, medical
records and/or reports with respect to any injury or illness, medical history, consultations,
treatment, patient questionnaires, progress notes, laboratory reports, nurses notes, bills on
account, hospital records, reports of diagnostic and surgical procedures, x-rays and x-ray
reports, narrative reports, office notes, permanency ratings, and any and all reports or
correspondence of physicians, hospitals, or any other persons included in your file and all
correspondence or any other records of any kind or nature that you have in your
possession regarding any claim of the above named person.
You have the right to make a legal objection to the production of these materials under
If you fail to comply, you may be
You may request reasonable costs for preparing these documents in advance by making
A copy of this Subpoena has been furnished to all counsel of record.
COMPLIANCE WITH HIPAA DISCLOSURE
Defendant has complied with 45 C.F.R., Section 164.512(e) and Rule 1.351 of the
Undersigned certifies that:
1) Written notice has been provided to the insurance and/or the individual’s attorney for
whom the documents are sought,
2) The notice included sufficient information about the litigation and/or proceeding to
permit the individual or his/her at
documents,
3) The time to raise an objection has elapsed and,
4) Neither the individual nor his/her attorney filed an objection to the above-listed
WITNESS my hand and seal on January 17, 2022
FRANCESCA A. IPPOLITO-CRAVEN
For the Court
/s/ Francesca Ippolito-Craven
Florida Bar Number 0145361
Francesca Ippolito-Craven, Esquire
KUBICKI DRAPER
9100 S. Dadeland Blvd.
Miami, Florida 33156
Telephone: (305) 982-6604
Facsimile: (305) 374-7846
If you are a person with a disability who needs any accommodation in order to
respond to this subpoena, you are entitled, at no cost to you, to the provision of
certain assistance. Please contact FRANCESCA IPPOLITO-CRAVEN of
Kubicki Draper at (305) 982-6737 at least 7 days before your scheduled
appearance, or immediately upon receiving this notification if the time before
the scheduled appearance is less than 7 days; if you are hearing or voice
impaired, call 711.
For questions regarding this Subpoena
FEDERAL RULE OF EVIDENCE 902 CERTIFICATION/DECLARATION OF
RECORDS CUSTODIAN
In accordance with Federal Rule of Evidence 902 Self-Authentication, I
___________________, Custodian of Records, do hereby produce the attached records of
Barbara Gonzalez; DOB: and do hereby certify that such records:
Were made at or near the time of the occurrence of the matters set forth by, or from
information transmitted by a person or persons with knowledge of the matters,
acting within the course of the regularly conducted business activity;
b) Were kept in the course of the regularly conducted business activity;
c) Were made as a regular practice in the course of the regularly conducted activity;
d) And are true and accurate copies of the original records.
I have read every statement made in this certification, and each statement is true and
correct. I understand that falsely making such a certification or declaration would subject
me to criminal penalty under the laws of the foreign or domestic location in which the
certification or declaration was signed.
Records Custodian’s Signature Date
Sworn to or affirmed and signed before me on this _____ day of ___________________,
Notary Public
My commission expires: