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Filing # 135253005 E-Filed 09/24/2021 11:40:00 AM
IN THE COUNTY COURT OF THE THIRTEENTH JUDICIAL CIRCUIT
1
IN AND FOR HILLSBOROUGH COUNTY, STATE OF FLORIDA
CWIL DIVISION
CINDY CHACON, CASE NO.: 21-CC-097763
DIVISION: S
Plaintiff,
v.
IMPERIAL FIRE AND CASUALTY
INSURANCE COMPANY,
A Foreign Profit Corporation
Authorized to do business
In Florida,
Defendant.
/
PLAINTIFF'S FIRST REQUEST
FOR ADMISSIONS TO DEFENDANT
PLAINTIFF, CINDY CHACON, by and through the undersigned attorney
and pursuant to Rule 1.370 of the Florida Rules of Civil Procedure serves this
Plaintiff's First Request For Admissions To Defendant, requesting the
Defendant to admit:
1. Admit the defendant is a corporation licensed to do business in the
State of Florida.
2. Admit the defendant is doing business in Hillsborough County, Florida.
3. Admit the defendant issued an automobile insurance agreement or policy
bearing contract or policy number 2008920517, providing contractual
and statutory Personal Injury Protection benefits to its insured,
Diana Calderin Chacon.
4. Admit the FL Personal Auto Declarations Pages attached and marked as
"Exhibit A" to the Petition For Declaratory Judgment is a true and
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correct copy of the applicable declarations page stating the coverages in
effect for the above referenced insurance agreement.
5. Admit the PLAINTIFF, CINDY CHACON, was involved in an automobile
collision on September 19, 2020; and she sustained bodily injuries as a
result of the collision.
6. Admit the PLAINTIFF, CINDY CHACON, at the time of the above
referenced loss, is a resident relative of the named insured, and is eligible
for Personal Injury Protection coverage in relation to the automobile
collision dated September 19, 2020.
7 . Admit the PLAINTIFF, CINDY CHACON, submitted an Application For
Florida "No Fault" Benefits to the Defendant dated October 28, 2020,
copy attached and marked as "Exhibit A."
8. Admit that the PLAINTIFF, CINDY CHACON, submitted a Sworn Affidavit
Of Non-Ownership to the Defendant dated October 28, 2020, copy
attached and marked as "Exhibit B."
9. Admit the DEFENDANT, IMPERIAL FIRE AND CASUALTY INSURANCE
COMPANY, qualified the PLANITIFF, CINDY CHACON as being eligible for
contractual and/ or statutory personal injury protection benefits by the
above referenced insurance agreement.
10. Admit the DEFENDANT, IMPERIAL FIRE AND CASUALTY
INSURANCE COMPANY, received medical bills of the PLAINTIFF, CINDY
CHACON, and processed initial medical bills received for payment under
the above referenced insurance agreement.
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11. Admit all medical bills received by the Defendant and paid by the
Defendant pursuant to the above referenced automobile insurance
agreement paid for medical bills that were reasonable, related and
necessary for the examination, diagnoses and treatment of the Plaintiffs
injuries.
12. Admit on May 3, 2021, the Defendant, through its vendor, JBA
Medical, issued correspondence scheduling the Plaintiff for notice no-
fault examination, scheduling her for Friday, May 14, 2021, a true and
correct copy of the notice of examination is attached to her petition,
marked as "Exhibit B."
13. Admit on May 10, 2021, the Plaintiff, by and through the
undersigned counsel, issued correspondence advising the Plaintiff had a
calendar conflict and could not reasonably attend unilaterally scheduled
examination, a true and correct copy the correspondence is attached to
her petition, marked as "Exhibit C."
14. Admit on May 12, 2021, the Defendant, through its vendor,
JBA Medical, issued second correspondence rescheduling the Plaintiff for
notice of examination, rescheduling her for Friday, May 20, 2021, a true
and correct copy of the correspondence is attached to her petition,
marked as "Exhibit D."
15. Admit the PLAINTIFF, CINDY CHACON, attended the above
referenced examination scheduled on May 28, 2021; and the examiner
refused to examine the Plaintiff on the basis she would not complete a
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written questionnaire or intake forms not previously submitted to her
counsel for review and approval beforehand.
16. Admit on June 2, 2021, the Defendant, through its vendor,
JBA Medical, issued correspondence alleging Plaintiff did not appear for
the above referenced examination and rescheduled her for another
examination, scheduling her to be examined on Tuesday, June 15, 2021,
a true and correct copy of the notice of examination attached to her
petition and marked as "Exhibit E."
17. Admit on June 8, 2021, the Plaintiff, by and through the
undersigned counsel, issued correspondence to the Defendant's vendor,
JBA Medical, acknowledging receipt of correspondence of June 2, 2021,
noting the Plaintiff did not fail to attend the previously scheduled
examination, also noting the Plaintiff will attend a rescheduled
examination and a videographer would be present, a correct copy of the
correspondence attached to her petition and marked as "Exhibit F."
18. Admit on June 15, 2021, the Plaintiff attended Me above
referenced examination, appearing on the date, time and place to allow
an examination to occur; and at all times, the examiner refused to
examine the Plaintiff on the basis of a videographer being present.
19. Admit on June 17, 2021, the Defendant issued written
correspondence advising the carrier is denying or discontinuing
Personal Injury Protection benefits, alleging Plaintiff failed to attend to
examinations scheduled on May 28, 2021, and June 15, 2021, also
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advising decision to deny coverage based upon Florida law and the terms
and conditions of the insurance agreement, true and correct copy of
Defendant correspondence attached to her petition, marked as
"Exhibit G,"
20. Admit the Defendant's correspondence or coverage denial
(June 17, 2021) is not based upon accurate facts as the Plaintiff attended
both examinations as cited immediately above .
21. Admit the Defendant's correspondence or coverage denial
(June 17, 2021) is not based upon accurate facts as the examiner(s) at
both examinations unreasonably refused to examine the Plaintiff.
22. Admit the examining physician(s) chosen by the Defendant and/or
by the Defendant's vendor does not have any physician-patient
relationship with the Plaintiff; and each physician was retained only to
examine the Plaintiff at the Defendant's request pursuant to applicable
insurance agreement and Florida stauLltory law.
23. Admit the Defendant possessed a signed medical authorization of
the Plaintiff allowing Defendant the ability or access to obtain copy of any
and all medical records arising from the above referenced loss; and had
the ability to provide all medical records and related diagnostic films to
either examining physician prior to any scheduled exam.
24. Admit the above referenced insurance agreement and or
Florida law does not contain any language that would disallow or
prohibit the Plaintiff from attending any such requested examination in
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the presence of a videographer, the Plaintiff having every legal right to
have a videographer present at any exam scheduled.
25. Admit the Defendant's denial of coverage does not have an
accurate factual basis as she attended both exams scheduled by the
carrier or carrier's vendor.
26. Admit the Defendant's denial of coverage does not have any
legal basis to deny coverage; as, she attended both exams scheduled by
the carrier or the ca.rrier's vendor.
27. Admit the Defendant's denial of coverage is inconsistent with the
undisputed facts and Florida law; and the Defendant breached the
insurance agreement and applicable Florida law by denying such
coverage and denying payment of any bills received after.
28. Admit the Plaintiff met all conditions precedent to coverage and to
filing the Petition For Declaratory Relief.
29. Admit the Defendant received medical bills after its coverage denial
and has not paid such medical bills based upon its previous writing of
denying such coverage, denying Personal Injury Protection benefits on
the basis of alleging the Plaintiff unreasonably failed to attend to exams
scheduled by the Defendant.
SO. Admit the Defendant does not have any valid factual and or legal
basis to deny Personal Injury Protection coverage under the above
circumstances, especially knowing the Plaintiff attended both
examinations as cited within the Defendant's denial letter.
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WHEREFORE, PLAINTIFF, CINDY CHACON, by and through the
undersigned attorney and pursuant to Rule 1.370 of the Florida Rules of Civil
Procedure serves this Plaintiffs First Request For Admissions requesting
admission of the truth of the statements or opinions of fact or of the
application of law to face, including the genuineness of any documents
described or referenced above.
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that the foregoing was furnished to DEFENDANT,
IMPERIAL FIRE AND CASUALTY INSURANCE COMPANY, by Service of Process
along with the Summons and Complaint.
Respectfully §ulgmitted,
's 1
Bradley D. Souders, Esquire
Bradley D. Souders, P.A.
115 South Fielding Avenue
Tampa, Florida 33606
service-bsouders@tampabav.rr.com
(Pleadings)
brad@hoglaw1 .com
(Secondary email)
Telephone: (813) 254-5155
Facsimile: (813) 254-3756
Florida Bar No. 857718
Attorney for Plaintiff
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9/24/2021 11:40 AM Electronically Filed; Hillsborough County/13th Judicial Circuit Page 7
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Is .APPLICATION FOR FLORIDA "NO FAULT" BENEFITS
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DATE 'out POLICYHOLDER J 0'A AET r ` ACINNT FILE NUMBER
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TO ENABLEUS TO BETERMINE IF YOU ARE ENTITLED TO BENEFITS UNDER THE FLORIDA PERSONAL INJURY PRO-
TECTION LAW, PLEASE COMPLETE THIS FORM AND RETURN IT PROMPTLY
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EXHIBIT "A" ¢
9/24/2021 11:40 AM Electronically Filed; Hillsborough County/13th Judicial Circuit Page 8
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9/24/2021 11:40 AM Electronically Filed; Hillsborough County/13th Judicial Circuit Page 9
SWORN AFFIDAVIT OF NON-OWNERSHIP
RE: CLAIMAINT: Cindy Chacon
DATE OF LOSS: September 19, 2020
SWORN BEFORE ME on this day and personally appearing
Cindy Chacon, who upon being first duly sworn, states:
1. My name is Cindy Chacon, I am over the age of eighteen and have
personal knowledge of these matters.
2. On September 19, 2020, was involved in a motor vehicle accident.
3. At the time of the accident, I resided at: 9703 E. Castle Court
Tampa, FL 33612.
4. Also at the time of the accident, I did not own'
8.. Any motor vehicle either operational or non-operational; and
b. Any automobile insurance agreement.
5. I hereby swear and ammo, under penalty of perjury, the above
statements are true and correct.
FURTHER AFFIANT SAYEFI-I NAUGHT. 8 1
Cindy Chacon
STATE OF FLORIDA
COUNTY OF HILLSBOROUGH
Cimds OAaL° is.
e foregoing instrument was acknowledged before me on this zwtfiay of
zz¢8law , 2 0 2 0 , gr Cind Chacon who: is personally
known by me; or, produced FL- Ai. casa */QUO* 99-.4»1¢?*0 for
identification, and who did take an oath verifying the above statements as true
and corr ct to the best of his/ her knowledge.
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EXHIBIT "Bas
9/24/2021 11:40 AM Electronically Filed; HillsboFeugh€otmtyH8th Judicial Circuit Page 10
Preview
Filing # 135253005 E-Filed 09/24/2021 11:40:00 AM IN THE COUNTY COURT OF THE THIRTEENTH JUDICIAL CIRCUIT 1 IN AND FOR HILLSBOROUGH COUNTY, STATE OF FLORIDA CWIL DIVISION CINDY CHACON, CASE NO.: 21-CC-097763 DIVISION: S Plaintiff, v. IMPERIAL FIRE AND CASUALTY INSURANCE COMPANY, A Foreign Profit Corporation Authorized to do business In Florida, Defendant. / PLAINTIFF'S FIRST REQUEST FOR ADMISSIONS TO DEFENDANT PLAINTIFF, CINDY CHACON, by and through the undersigned attorney and pursuant to Rule 1.370 of the Florida Rules of Civil Procedure serves this Plaintiff's First Request For Admissions To Defendant, requesting the Defendant to admit: 1. Admit the defendant is a corporation licensed to do business in the State of Florida. 2. Admit the defendant is doing business in Hillsborough County, Florida. 3. Admit the defendant issued an automobile insurance agreement or policy bearing contract or policy number 2008920517, providing contractual and statutory Personal Injury Protection benefits to its insured, Diana Calderin Chacon. 4. Admit the FL Personal Auto Declarations Pages attached and marked as "Exhibit A" to the Petition For Declaratory Judgment is a true and 1 9/24/2021 11:40 AM Electronically Filed; Hillsborough County/13th Judicial Circuit Page 1 correct copy of the applicable declarations page stating the coverages in effect for the above referenced insurance agreement. 5. Admit the PLAINTIFF, CINDY CHACON, was involved in an automobile collision on September 19, 2020; and she sustained bodily injuries as a result of the collision. 6. Admit the PLAINTIFF, CINDY CHACON, at the time of the above referenced loss, is a resident relative of the named insured, and is eligible for Personal Injury Protection coverage in relation to the automobile collision dated September 19, 2020. 7 . Admit the PLAINTIFF, CINDY CHACON, submitted an Application For Florida "No Fault" Benefits to the Defendant dated October 28, 2020, copy attached and marked as "Exhibit A." 8. Admit that the PLAINTIFF, CINDY CHACON, submitted a Sworn Affidavit Of Non-Ownership to the Defendant dated October 28, 2020, copy attached and marked as "Exhibit B." 9. Admit the DEFENDANT, IMPERIAL FIRE AND CASUALTY INSURANCE COMPANY, qualified the PLANITIFF, CINDY CHACON as being eligible for contractual and/ or statutory personal injury protection benefits by the above referenced insurance agreement. 10. Admit the DEFENDANT, IMPERIAL FIRE AND CASUALTY INSURANCE COMPANY, received medical bills of the PLAINTIFF, CINDY CHACON, and processed initial medical bills received for payment under the above referenced insurance agreement. 2 9/24/2021 11:40 AM Electronically Filed; Hillsborough County/13th Judicial Circuit Page 2 11. Admit all medical bills received by the Defendant and paid by the Defendant pursuant to the above referenced automobile insurance agreement paid for medical bills that were reasonable, related and necessary for the examination, diagnoses and treatment of the Plaintiffs injuries. 12. Admit on May 3, 2021, the Defendant, through its vendor, JBA Medical, issued correspondence scheduling the Plaintiff for notice no- fault examination, scheduling her for Friday, May 14, 2021, a true and correct copy of the notice of examination is attached to her petition, marked as "Exhibit B." 13. Admit on May 10, 2021, the Plaintiff, by and through the undersigned counsel, issued correspondence advising the Plaintiff had a calendar conflict and could not reasonably attend unilaterally scheduled examination, a true and correct copy the correspondence is attached to her petition, marked as "Exhibit C." 14. Admit on May 12, 2021, the Defendant, through its vendor, JBA Medical, issued second correspondence rescheduling the Plaintiff for notice of examination, rescheduling her for Friday, May 20, 2021, a true and correct copy of the correspondence is attached to her petition, marked as "Exhibit D." 15. Admit the PLAINTIFF, CINDY CHACON, attended the above referenced examination scheduled on May 28, 2021; and the examiner refused to examine the Plaintiff on the basis she would not complete a 3 9/24/2021 11:40 AM Electronically Filed; Hillsborough County/13th Judicial Circuit Page 3 written questionnaire or intake forms not previously submitted to her counsel for review and approval beforehand. 16. Admit on June 2, 2021, the Defendant, through its vendor, JBA Medical, issued correspondence alleging Plaintiff did not appear for the above referenced examination and rescheduled her for another examination, scheduling her to be examined on Tuesday, June 15, 2021, a true and correct copy of the notice of examination attached to her petition and marked as "Exhibit E." 17. Admit on June 8, 2021, the Plaintiff, by and through the undersigned counsel, issued correspondence to the Defendant's vendor, JBA Medical, acknowledging receipt of correspondence of June 2, 2021, noting the Plaintiff did not fail to attend the previously scheduled examination, also noting the Plaintiff will attend a rescheduled examination and a videographer would be present, a correct copy of the correspondence attached to her petition and marked as "Exhibit F." 18. Admit on June 15, 2021, the Plaintiff attended Me above referenced examination, appearing on the date, time and place to allow an examination to occur; and at all times, the examiner refused to examine the Plaintiff on the basis of a videographer being present. 19. Admit on June 17, 2021, the Defendant issued written correspondence advising the carrier is denying or discontinuing Personal Injury Protection benefits, alleging Plaintiff failed to attend to examinations scheduled on May 28, 2021, and June 15, 2021, also 4 9/24/2021 11:40 AM Electronically Filed; Hillsborough County/13th Judicial Circuit Page 4 advising decision to deny coverage based upon Florida law and the terms and conditions of the insurance agreement, true and correct copy of Defendant correspondence attached to her petition, marked as "Exhibit G," 20. Admit the Defendant's correspondence or coverage denial (June 17, 2021) is not based upon accurate facts as the Plaintiff attended both examinations as cited immediately above . 21. Admit the Defendant's correspondence or coverage denial (June 17, 2021) is not based upon accurate facts as the examiner(s) at both examinations unreasonably refused to examine the Plaintiff. 22. Admit the examining physician(s) chosen by the Defendant and/or by the Defendant's vendor does not have any physician-patient relationship with the Plaintiff; and each physician was retained only to examine the Plaintiff at the Defendant's request pursuant to applicable insurance agreement and Florida stauLltory law. 23. Admit the Defendant possessed a signed medical authorization of the Plaintiff allowing Defendant the ability or access to obtain copy of any and all medical records arising from the above referenced loss; and had the ability to provide all medical records and related diagnostic films to either examining physician prior to any scheduled exam. 24. Admit the above referenced insurance agreement and or Florida law does not contain any language that would disallow or prohibit the Plaintiff from attending any such requested examination in 5 9/24/2021 11:40 AM Electronically Filed; Hillsborough County/13th Judicial Circuit Page 5 the presence of a videographer, the Plaintiff having every legal right to have a videographer present at any exam scheduled. 25. Admit the Defendant's denial of coverage does not have an accurate factual basis as she attended both exams scheduled by the carrier or carrier's vendor. 26. Admit the Defendant's denial of coverage does not have any legal basis to deny coverage; as, she attended both exams scheduled by the carrier or the ca.rrier's vendor. 27. Admit the Defendant's denial of coverage is inconsistent with the undisputed facts and Florida law; and the Defendant breached the insurance agreement and applicable Florida law by denying such coverage and denying payment of any bills received after. 28. Admit the Plaintiff met all conditions precedent to coverage and to filing the Petition For Declaratory Relief. 29. Admit the Defendant received medical bills after its coverage denial and has not paid such medical bills based upon its previous writing of denying such coverage, denying Personal Injury Protection benefits on the basis of alleging the Plaintiff unreasonably failed to attend to exams scheduled by the Defendant. SO. Admit the Defendant does not have any valid factual and or legal basis to deny Personal Injury Protection coverage under the above circumstances, especially knowing the Plaintiff attended both examinations as cited within the Defendant's denial letter. 6 9/24/2021 11:40 AM Electronically Filed; Hillsborough County/13th Judicial Circuit Page 6 WHEREFORE, PLAINTIFF, CINDY CHACON, by and through the undersigned attorney and pursuant to Rule 1.370 of the Florida Rules of Civil Procedure serves this Plaintiffs First Request For Admissions requesting admission of the truth of the statements or opinions of fact or of the application of law to face, including the genuineness of any documents described or referenced above. CERTIFICATE OF SERVICE I HEREBY CERTIFY that the foregoing was furnished to DEFENDANT, IMPERIAL FIRE AND CASUALTY INSURANCE COMPANY, by Service of Process along with the Summons and Complaint. Respectfully §ulgmitted, 's 1 Bradley D. Souders, Esquire Bradley D. Souders, P.A. 115 South Fielding Avenue Tampa, Florida 33606 service-bsouders@tampabav.rr.com (Pleadings) brad@hoglaw1 .com (Secondary email) Telephone: (813) 254-5155 Facsimile: (813) 254-3756 Florida Bar No. 857718 Attorney for Plaintiff 7 9/24/2021 11:40 AM Electronically Filed; Hillsborough County/13th Judicial Circuit Page 7 Tone.onoencAu. §"."£4'!*§! nsoazuasu \ » \ v a Is .APPLICATION FOR FLORIDA "NO FAULT" BENEFITS . ;' NAME OF s INSURANCE I COMPANY: DATE 'out POLICYHOLDER J 0'A AET r ` ACINNT FILE NUMBER 0 - DO TO ENABLEUS TO BETERMINE IF YOU ARE ENTITLED TO BENEFITS UNDER THE FLORIDA PERSONAL INJURY PRO- TECTION LAW, PLEASE COMPLETE THIS FORM AND RETURN IT PROMPTLY fTmpem\ ~;€,Q< Qw~sw lw.,a<»m"1 T O: CLAIM DEPARTMENT ®mo&"% AIN PERSON who momuoLyuamm m» TENT TO INJUHE, DEFRALD, OH necaveurr INSURER mes ASTATEMEUOF CLAIM on AN AFFUCATI0N COHTAIMNG ANY ruse. I RELATION TO INSURED Pl.I %N E l I INCQMPLETE. OR NISLEADING IHFQRMATIOH 18 GUILTY DF AFELDNY OF Kano nesnzs. l BUSINESS YO R.NA \ UJ I w \ I y°g : ADDRES u inn ' | » STRE (Mow OR T •WN, STATE AND ZIP CODE) I . • \ \ A \ I o -I 0% as+ box o PERMANENT ADDRESS, IF OIFF'E ENT I '. I ¥ al 0a Fl 42117 I Ho LONGHAVEYQU Llveu In s=Lo"aluA-e LL . 01I So f (No,; . P L AC OF ACCIDE{4 STREET, CITY OR TOWN AND STATE) I \ DQ' ?°\`4M'}'388° E'1lT;3 BRIEF DESCR PTI| \ o p.m.. ACCIDE T A I I |-||CLE v:ln r.a ~n oL to: I n QU L. 4944 I •U a¢ O| so I Q 1 l I u l I I | on I | l l • UIC . . baseman MOTGR VEHICLE you OWN- I liver ii+»¥ 'm may We oascmne MOTOR VEHICLE OWN | I Y ANY M8HBER OF youR FAMILY IN OUR HOUSBHDLIL . I 0/ 751/84, I~'J uuwz, I I NO I J • IF YOUR ANSWER IS YES, COMPLETE THE REST OF THIS FORM. AS A RESULT OF THIS ACCIDENT WERE YOU INJURED YES '. IF NO, SIGN HERE AND RETURN HIS FO o us, S IG NAT UR E : cAre» IO -Q2;-2030 DESCRI EYOUR INJURY: ./... .....[l4l1r1...1A,{2...l'P........ II•|vI I I Hznu) .:' YOU TR .Qllwx Q I # Of . l_I b .Pq.lr\ ; DOCTOR? ED BY A vase' NO DO TOR' NAMEAND D 'I . IFYOU WERETHEATED IN A HOSPITAL, WERE HOSPITALS NAM n ESS WD I I a, ; ND ADDRESS • / I P. A m222x I \ 1 fin!! \ YOU AN IN-PATIENT? AMOUNT OF M D OUT-PATIENT? 4 AL BlLLS.TO WILLYOU HAVE MORE MEDICAL AT THE TIME OF YOUR ACCIDENT WERE YOU IN THE COURSE OF DATE s / / I 8 DID YOU Los WAGES OR SALARY AS A RESU T EXPENSE? yes8/no EMPLOYMENT? IF YES, AMOUNT LOST TO YES WHAT IS yOUR AVERAGE NM EKLY WAGE oF YOUR INJURY? . YES C NO n Al'e s / OR SALARY? s /5*. | IF YOU LOST WAGES: DATE m 1 : ILITY FROM W ORK BEGAN A I HAVE you RECEIVED. OH ARE YOU ELIG BLE FOR PAYMENTS UNDER ANY WORKMEN'S VF YES, A • NT PER WEEK PER MONTH DATE YOU RETURN 9 o WORK A . COMPENSATION OR UNEMPLOYMENT LAW? YES NO 9/' s I LISTNAMES AND AuunEss roun PRESENT EMPLOYEMS) AND GIVE YOUR OGCUPATION AND DATES OF EMPLOYMENT FOR EACH: 1n °°'l'5°° II "€IW§i§6Véii 8E§§' s . 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AII~uawsa»1n • - Q . • 0 . 9/24/2021 11:40 AM Electronically Filed; Hillsborough County/13th Judicial Circuit Page 9 SWORN AFFIDAVIT OF NON-OWNERSHIP RE: CLAIMAINT: Cindy Chacon DATE OF LOSS: September 19, 2020 SWORN BEFORE ME on this day and personally appearing Cindy Chacon, who upon being first duly sworn, states: 1. My name is Cindy Chacon, I am over the age of eighteen and have personal knowledge of these matters. 2. On September 19, 2020, was involved in a motor vehicle accident. 3. At the time of the accident, I resided at: 9703 E. Castle Court Tampa, FL 33612. 4. Also at the time of the accident, I did not own' 8.. Any motor vehicle either operational or non-operational; and b. Any automobile insurance agreement. 5. I hereby swear and ammo, under penalty of perjury, the above statements are true and correct. FURTHER AFFIANT SAYEFI-I NAUGHT. 8 1 Cindy Chacon STATE OF FLORIDA COUNTY OF HILLSBOROUGH Cimds OAaL° is. e foregoing instrument was acknowledged before me on this zwtfiay of zz¢8law , 2 0 2 0 , gr Cind Chacon who: is personally known by me; or, produced FL- Ai. casa */QUO* 99-.4»1¢?*0 for identification, and who did take an oath verifying the above statements as true and corr ct to the best of his/ her knowledge. n o 0 C22 » Male Printed NQ61€2 4.4418 Notary Stamp: KELLYACOATS Mvvvuauc-sunwFlul1¢a Guaunwnuaeeusesaa M1cu=Iun&mi1usFeb8.2n2l 8°II¢1l4Wl1u9lllainlmlI¢¢llly&i1n. EXHIBIT "Bas 9/24/2021 11:40 AM Electronically Filed; HillsboFeugh€otmtyH8th Judicial Circuit Page 10