STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATSON iz =f rn # FLORIDA REAL ESTATE COMMISSION = qi FLORIDA DEPARTMENT OF BUSINESS on APR ~ ~b A lt: O54 AND PROFESSIONAL REGULATION, 6 DIVISION OF REAL ESTATE, “wiaige apts SION OF Fs eS Tar - HEARIN IVE Petitioner, v. DBPR Case N° 2008043166 BRAHMS ALEXIS, Respondent. ADMINISTRATIVE COMPLAINT State of Florida, Department of Business and Professional Regulation, Division of Real Estate (“Petitioner”) files this Administrative Complaint against Brahms Alexis (“Respondent”) - and alleges ESSENTIAL ALLEGATIONS OF MATERIAL FACT 1. Petitioner is a state government licensing and regulatory agency charged with the responsibility and duty to prosecute Administrative Complaints pursuant to the laws of the State of Florida, in particular Section 20.165 and Chapters 120, 455 and 475, of the Florida Statutes and the rules promulgated pursuant thereto. 2. Respondent is and was at all times material hereto a licensed Florida real estate sales associate, issued license number 3206812 in accordance with Chapter 475 of the Florida Statutes. 3. The last license issued was as an inactive sales associate Hilaclalexis.doc 1 FDBPR v. Brahms Alexis Case No. 2008043166 Administrative Complaint — at 3820 NW 107° Terrace, Sunrise, Florida 33351. 4. At all times material, Respondent was also the holder of a mortgage broker’s license issued by the State of Florida Office of Financial Regulation. 5. On or about August 28, 2007, Respondent appeared before William F. Reilly, Jr., appointed informal hearing officer to determine what type of disciplinary action should be imposed on Respondent, the holder of a mortgage broker’s license for violations to Chapter 494, Florida Statutes. A copy of the penalty is attached hereto and incorporated herein as Administrative Complaint Exhibit 1. oo —-G;—- Respondent-admitted_to-the hearing-officer that.on or... - about June 28, 2006, the the Circuit Court of the Seventeenth Judicial Circuit in and for Broward County, Florida, the Respondent pled no contest to the criminal use of personal identification information, a third degree felony in the State of Florida. 7. On or about May 8, 2008, Donald B. Saxon, Commissioner, Office of Financial Regualtions, adopted in full the finding of facts, conclusions of law and the hearing officer's recommendation whereas, Respondent’s mortgage broker's license was revoked. H\aclalexis.doc 2 FDBPR v. Brahms Alexis Case No. 2008043166 Administrative Complaint COUNT ONE Based upon the foregoing, Respondent is guilty of having had a registration suspended, revoked, or otherwise acted against in any jurisdiction in violation of Section 475.25(1)(s), Florida Statutes. WHEREFORE, Petitioner respectfully requests the Florida Real Estate Commission, or the Department of Business and Professional Regulation, as may be appropriate, to issue a Final Order as final agency action finding the Respondent(s) guilty as charged. The penalties which may be imposed for violation(s) of Chapter 475 of the Florida Statutes, depending upon the severity of the include: revocation of the license or registration or permit; suspension of the license, registration or permit for a period not to exceed ten (10) years, imposition of an administrative fine of up to $5,000 for each count or offense; imposition of investigative costs; issuance of a reprimand; imposition of probation subject to terms including, but not limited to, requiring the licensee, registrant or permitee to complete and pass additional real estate education courses; publication; or any combination of the foregoing which may apply. See Section 475.25(1), Florida Statutes and Florida Administrative Code Rule 6132-24.001. The penalties which may be imposed for violation(s) of Chapter 455 of the Florida Statutes, depending upon the severity Hitaclalexis.doc 3 FDBPR v. Brahms Alexis Case No. 2008043166 Administrative Complaint of the offense(s), include: revocation of the license, registration, or permit; suspension of the license, registration, or permit for a period not to exceed ten (10) years; imposition of an administrative fine of up to $5,000 for each count or offense; imposition of investigative costs; issuance of a reprimand; imposition of probation subject to terms including, but not limited to, requiring the licensee, registrant, or permitee to complete and pass additional real estate education courses; publication; restriction of practice; injunctive or mandamus relief; imposition of a cease and desist notice; or any combination of the foregoing ‘which may apply. See Section 455.227, Florida Statutes and Florida Administrative Code Rule 61J2-24.001. SIGNED this\ day off nae Vide > , 2008. Department of Business a Professional Regulation Thomas O’Bryant, Jr. Director, Division of Real Esta! H:\ac\alexis.doc 4 FDBPR v. Brahms Alexis Case No. 2008043166 Administrative Complaint ATTORNEY FOR PETITIONER James Patrick Harwood Senior Attorney Florida Bar N° 425941 Division of Real Estate Department of Business and Professional Regulation, Legal Section - Suite N 801 Hurston Bldg. North Tower 400 West Robinson Street Orlando, Florida 32801-1757 (407) 481-5632 (407) 317-7260 FAX _ "NOTICE TO RESPONDENTS = PLEASE BE ADVISED that mediation under Section 120.573 of the Florida Statutes, is not available for administrative disputes involving this type of agency action. PLEASE BE FURTHER ADVISED that pursuant to this Administrative Complaint you may request, within the time allowed by law, a hearing to be conducted in this matter in accordance with Sections 120.569 and 120.57 of the Florida Statutes; that you have the right, at your option and expense, to be represented by counsel or other qualified representative in this matter; and that you have the right, at your option and expense, to take testimony, to call and cross-examine witnesses, and to have subpoena and subpoena duces tecum issued on your behalf if a formal hearing is requested. PLEASE BE FURTHER ADVISED that if you do not file an Election of Rights form or some other responsive pleading with the Petitioner within twenty-one (21) days of receipt of this Administrative Complaint, the Petitioner will file with the Florida Real Estate Commission a motion requesting an informal hearing and entry of an appropriate Final Order which may result in the suspension or revocation of your real estate license or registration. Please see the enclosed Explanation of Rights and Hi\aclalexis.doc 5 FDBPR v. Brahms Alexis Administrative Complaint Election of Rights form. Hiac\alexis.doc Case No. 2008043166 STATE OF FLORIDA _ OFFICE OF FINANCIAL REGULATION IN RE: Administrative Proceeding Numbers ALEXIS MORTGAGE ENTERPRISE 1814-F-1/07 GROUP, INC. and 1814a-F-1/07 BRAHMS ALEXIS, individually and as president/owner of Alexis Mortgage Enterprise Group, Inc. Respondents. FINAL ORDER Upon due notice, this cause came on for informal hearing before William F. Reilly, Jr., a duly appointed informal hearing officer for the Office of Financial Regulation, on August 28, 2007 at the Office of Financial Regulation, 1400 West Commercial Boulevard, Suite 135, Fort Lauderdale, Florida. Appearances For Petitioner: Tobi C. Pam Assistant General Counsel Office of Financial Regulation — 1400 West Commercial Boulevard Suite 135 Fort Lauderdale, FL 33309 For Respondent: Anastasia Alexis Qualified Representative 3820 N.W. 107° Terrace Sunrise, FL 33351 pace [Oh EXHIBIT. / _ PAGE. STATEMENT OF THE ISSUES The issue in this proceeding is what type of disciplinary action should be imposed on Brahms Alexis’ (“Alexis”) mortgage broker license and against Alexis Mortgage Enterprise Group, Inc.’s (“Alexis Mortgage”) mortgage brokerage business license. PRELIMINARY STATEMENT The Office of Financial Regulation (“Office”) filed an Administrative Complaint and Notice of Rights against Alexis and Alexis Mortgage on January 16, 2007, On January 30, 2007, Alexis and Alexis Mortgage filed a request for informal hearing with the Office. On March 27, 2007, the Office entered an Order Granting Informal Hearing and Appointing Informal Hearing Officer. This Order advised the parties that if any party desired to present oral evidence, the party would be required to provide the informal hearing. officer with a. written statement as to the nature of and the > necessity for presenting such oral evidence within ten calendar days of the date of the Order. “if the parties did not desire to present oral evidence, the parties would have thirty calendar days from the date of the Order in which to present all written statements, documents, pleadings, memoranda of law, or otber written materials to the hearing officer. Pursuant thereto, Alexis and Alexis Mortgage iimely filed a request to present oral evidence. An informal hearing was held in this cause on August 28, 2007 in Fort Lauderdale, Florida. The Office moved four exhibits into evidence. Alexis and Alexis Mortgage moved six exhibits into evidence. Alexis testified on behalf of himself and Alexis Mortgage. Alexis and Alexis Mortgage also presented the testimony of Anna Alexis. SOTRATIVE COMPLI ae cence nramumonneneinine cece ete SOON EIEN enanrr. ___ PAGE D2 No material facts are in dispute nor were they placed in dispute through the documents and testimony submitted to the Informal Hearin formal administrative hearing. FINDINGS OF FACT SAND LN SD OS g Officer so as to necessitate a 1. The Office is the agency charged with the responsibility and duty of administering and enforcing the provisions of Chapter 494, promulgated thereunder. Florida Statutes and the rules 2. At all times material hereto, Alexis has been licensed with the Office as a mortgage broker having been issued an MB license on or about November 23, 2004. 3. At all times material hereto, Alexis has been an owner, the president, and the principal broker of Alexis Mortgage. a Office At all times material hereto, Alexis Mortgage has been licensed with the as a mortgage brokerage business having been issued an MBB license on or about January 21, 2005. 5. The last known address for Alexis Mortgage is 2324 North Dixie Highway, Hollywood, Florida. the Court withheld adjudication of guilt for one coun identification information i Number 05-14942090B in the Circuit Court of the 17" 6. On or about June 28, 2006, Alexis entered a Broward County, Florida. plea of nolo contendere and t of criminal use of personal ‘n violation of Section 8 17.568(2)(a), Florida Statutes in Case Judicial Circuit in and for EXHIQIT. Z pace 7. On or about June 28, 2006, Alexis was placed on probation for a period of 18 months. 8, On May 21, 2007, Alexis was notified that he had completed the term of supervision and was no longer under the supervision of the Department of Corrections. 9. Anna Alexis testified to the following regarding the criminal case against Alexis: a) On or about July 25, 2006, Alexis was approached by a woman named HE 20 be thought was a licensed realtor; b) MMMM gave Alexis a copy of a real estate contract and the information for a buyer named iy c) Alexis contacted EEE by phone, and she gave him permission and information so he could obtain a mortgage loan for her; d Alexis called the seller’s realtor, os confirmed that he buying a home for which he was the seller’s realtor; e) Alexis proceeded to qualify == for a mortgage; f) Alexis believed the purchase price of the home to be $890,000 with a $10,000 escrow deposit that was being held at a title company that the seller chose; g) After the contract was provided to Alexis, he toid ZN that he needed her to sign the mortgage documents in order for him to send them to the lender; h) MEE said she would come into the office later in the week to sign them but it would be late in the day; OMINISTRATIVE 4. Plo we EAE co EXHIQIT, WA i) Alexis could not be present so he left the documents with his secretary; jp His secretary stated in a letter that on or around July 25, 2006, a woman posing as RENN came to the office and signed the documents left by Alexis; k) After MEE signed the documents, Alexis applied for a mortgage loan on her behalf; 1) The mortgage was subsequently approved; m) Alexis received a copy of the settlement statement prior to closing and advised Zi__—_-7 that she needed to bring $100,000 to the closing; . n) ERR advised Alexis that she was unable to attend the closing on the scheduled date and asked him to reschedule it; 0) Alexis informed the title company which then advised the seller; p) The title company then advised Alexis that if the closing was not going to q Alexis called IEE and informed her that if the loan did not close as scheduled, “the deal would be dead;” 1) EES then contacted Alexis and told him that she would be present at the closing as scheduled; s) Alexis was arrested when he appeared at the closing; t) Apparently Ea was not who she said she was and 4 was not an active realtor; u) Alexis was charged with criminal use of identification and several counts of grand theft; mawar_/ pace 22 v) All charges were dropped except for criminal use of identification because MENS said she did not give her information to anybody, and the woman who posed as NE pled guilty; w) Alexis pled noio on advice of counsel, x) has since pled guilty and INI maintains that he did not know anything about the fraud; y) There was no gain for Alexis to engage in fraudulent activity except that he was going to earn a mortgage fee; 2) Alexis had done prior business with [J which had gone smoothly, and he had no reason to mistrust her or suspect she was engaging in fraudulent activity. 10. Alexis testified that in the state of Florida, a lot of people don’t go looking for financing before they look for a property; they go to the realtor first and then look for financing. They therefore build a stronger bond with their realtors, and therefore he often ends up dealing with the realtor more than the borrower. 11. Alexis testified that he has learned from this experience. 12. Alexis testified that he has been to several radio shows, especially in the Haitian community, to discuss his situation because Haitians are often the easiest people to be victimized by mortgage fraud because of the language barrier. 13. Alexis testified that he has been to the Gold Coast Schoo! of Real Estate to tell the students what happened in his situation. 14. Alexis testified that this is the career he wants to pursue for many years to come because he wants to keep helping people make their dreams come true. EMHUUET / paceg_/ _ proceed with the mortgage because Alexis is a person of good moral character. 15. Alexis testified that he is regretful for not protecting himself better and more importantly his client 16. Alexis testified that he has no employees at Alexis Mortgage. 17. _ Alexis testified that he has changed his business practice in that now he gets a copy of the borrower’s social security card and a copy of the borrower’s driver’s license before he gets the application. He also makes sure that he meets the borrower face to face no matter how busy he is. 18. Anna Alexis testified that she is a licensed realtor and if she is working on a file for which Alexis is the mortgage broker, they sit down with the borrower and explain exactly what happened with Alexis, and it is the borrower’s decision at that time to decide whether the borrower trusts Alexis enough to proceed. 19. Anna Alexis testified that they have never had a borrower decide not to 20. Anna Alexis testified that had Alexis had these procedures in place and had he physically gone to meet with IEEE perhaps he would not be in this situation. 21. Anna Alexis testified that if Alexis is doing a loan for an out-of-state client, be will drive out of state to meet the client. 22. Alexis provided a letter from Daniel P. Coco, a licensed real estate broker and an instructor at the Gold Coast School of Real Estate, stating that he had Alexis in his real estate class, that he found him to be an honest and ethical individual, and that Alexis had explained his situation to the class. EXHISIT, 7 page? 2 CONCLUSIONS OF LAW 23. The Office has jurisdiction over the subject matter and parties to this proceeding pursuant to Section 120.57(2), Florida Statutes and Chapter 494, Florida Statutes. 24. Section 494.0041(1), Florida Statutes, enables the Office to enter an order imposing one or more of the following penalties whenever it finds a person in violation of an act specified in section 494.0041(2), Florida Statutes: revocation of a license, suspension of a license, placement of the licensee on probation, issuance of a reprimand, imposition of a fine. 25. Section 494,0041(2)(a), Florida Statutes, provides that pleading nolo contendere to, or having been convicted or found guilty of, regardless of whether adjudication was withheld, a crime involving fraud, dishonest dealing, or any act of moral cornea turpitude, is grounds for which the disciplinary actions specified in section 494.0041(1), Florida Statutes, may be taken. 26. Section 494.0041(3), Florida Statutes provides that a mortgage brokerage business is subject to the disciplinary actions specified in subsection (1) for a violation of subsection (2) by any officer, director, joint venturer, partner, ultimate equitable owner of a 10% or greater interest in the mortgage brokerage business or associate mortgage broker of the licensee. 27. In Department of Banking and Finance v. Osborne Stem & Co., 670 So.2d 932, 935 (Fla. 1996), the Florida Supreme Court stated that “clear and convincing evidence is the proper standard in license revocation proceedings because they are penal in nature and implicate significant property rights.” EXHIQIT. 7 PAGE. 23 28. The Florida Supreme Court has agreed with the district court in Reid v. Florida Real Estate Commission, 188 So.2d 846,851 (Fla.2d DCA 1966) which stated that “the power to revoke a license should be exercised with no less careful circumspection than the original granting of it. And the penal sanctions should be directed only toward those who by their conduct have forfeited their right to the privilege, and then only upon clear and convincing proof of substantial causes justifying the forfeiture.” Ferris v. Turlington, 510 So.2d 292 (Fla. 1987) 29. Rule 69V-40.001(11), Florida Administrative Code defines moral turpitude as “duties owed by persons to society as well as acts contrary to justice, honesty, principle, or good morals.” 30. Section 817.568(2)(a), Florida Statutes, the crime for which Alexis entered the nolo plea, provides that “any person who willfully and without authorization fraudulently uses, OF wr possesses with intent to > fraudulently use, , personal identification — information concerning an individual without first obtaining that individual’s consent, commits the offense of fraudulent use of personal identification information, which is a felony of the third degree.” 31. There is clear and convincing proof in this case of substantial causes to justify the revocation of Alexis’s mortgage broker license and therefore the mortgage brokerage business license of Alexis Mortgage. He pled nolo contendere to one count of criminal use of personal identification in June 2006. Alexis committed this crime in the course of doing mortgage business and using his mortgage broker license. His crime clearly fits within the definition of Section 494.0041 (2)(a) of a crime involving fraud, ‘enon 1. race. 2p ‘onest g® O moral turpitude; in fact, his crime fits within the definition of all AOnest ¢ po, ; bree, , x Tn an explanation of the charges against Alexis, Anna Alexis explained ‘that Ate did not know that the person claiming to be I .,,.; not in fact wo spaid she was, and intimated that Alexis was an unwitting Participant in the - fraygent activiy. Itis noted that this testimony was not presented through Alexis Aimelt, who ¥s under oath, but instead through Anna Alexis as hearsay. The Office rejects this exience as unfie, Regardless, a licensed Mortgape broker has a fiduciary duty and regonsibility ensure that the loan documents less submitting to a lender are accurate, — ation in which he found himself. He also provided 34, f Although Alexis has taken Positive steps to learn from his Conviction ang seems sincere in his commitment to continue these efforts, not enough time has Passed since he has been released from Probation to show that he has been rehabilitated, RECOMMENDED ORDER ASS-OUMMENDED ORDER Based on the foregoing F indings of Fact and Conclusions of Law, itis hereby recommended that a Final Order be entered requiring that: 1. Brahms Alexis’ Mortgage broker license is revoked; 10 eam pyce 3) 2. “Alexis Mortgage Enterprise Group, Inc.’s mortgage brokerage business license is revoked. WILLIAM F. REILLY, JR. Informal Hearing Officer FINAL ORDER The foregoing Findings of Fact and Conclusions of Law by the Informal Hearing Officer are adopted in full in this Final Order. Based on the foregoing Findings of Fact, Conclusions of Law, and Informal Hearing Officer’s Recommendations, it is hereby ORDERED that: 1. Brahms Alexis’ mortgage broker license is revoked; 2. Alexis Mortgage Enterprise Group, Inc.’s mortgage brokerage business license is revoked. ~ 0 eee eee DONE AND ORDERED this HK, of, Ma _ , 2008 in Tallahassee, Leon County, Florida. DONALD B. SAXON, Commissioner Office of Financial Regulation COMPLAINT, il so cme A ie AIST SMMISIT, sD me PAGE DS NOTICE OF RIGHT TO JUDICIAL REVIEW A party who is adversely affected by this Final Order may seek judicial review pursuant to Section 120.68, Florida Statutes. Judicial review shall be instituted by filing a Notice of Appeal or Petition for Review in accordance with the Rules of Appellate Procedure within thirty (30) days of the rendition of this Final Order. One copy of the Notice or Petition shall be filed with the Agency Clerk for the Office of Financial Regulation, Legal Services Office, Fletcher Building, Suite 526, 200 East Gaines Street, Tallahassee, Florida 32399-0379, and a second copy shall be filed, along with the appropriate filing fee, with the Clerk of the District Court of Appeal, First District, 300 Martin Luther King, Jr. Boulevard, Tallahassee, Florida 32399-1850, or with the Clerk of the District Court of Appeal wherein the adversely affected party resides. CERTIFICATE OF SERVICE CERIIPM AM vas 1 HEREBY CERTIFY that a true and correct copy of the foregoing Final Order was sent by U.S. Mail to Brahms Alexis, individually and as president/owner of Alexis Mortgage Enterprise Group, Inc. at 3820 N.W. 107" Terrace, Sunrise, FL 333511 this 9 day of Lists , 2008. . Schultz f Copies furnished to: Tobi C. Pam, Assistant General Counsel Andy Grosmaire, Bureau Chief Terence M. Straub, Director, Division of Finance Sharon Dawes, Area Financial Manager William F. Reilly, Jr., Informal Hearing Officer Qom 12 | ¥% ¥ ¥* BROWARD COUNTY 17th JUDICIAL CIRCUIT OF FLORIDA ¥ ¥ > Home | Online Services | FAQ | Fine Payments | My Account | Public Search | Downloads | Premium Search | Case Summary Broward County Case Number: 05014943CF10A State Reporting Number: 062005CF014943A88 Court Type: FELONY Case Type: FELONY Incident Date: 09/07/2005 Filing Date: 10/14/2005 Court Location: BROWARD COUNTY CENTRAL . * COURTHOUSE Case Status: CASE TRANSFERRED’ Case Parties First Middle Party Pps fe foe Key Dates - Future Scheduled Events There is no key date information available for this case. Counts Select BRO po fe CLOS FXXD8175684C + |CRIM USE OF PERSONAL ID iNFO po fe c10s , : fonts Po foo | CLOS FXXD8120142AA |GRAND THEFT IN THE 1ST DEGREE Related Cases Related Case Number 05014942CF10B TRANSFER - COMPANION Please click the "Pay Fine/Fee” button to check if fines or fees are due. * Click Here for clarification of the case status. 10/14/2005 |SHE Case Type Additional Text Case Detail NOTE: Selecting the "Case Detail" button will deduct one unit from your account. Perform Another Search [8 Broward County Clerk of the Courts Contact Us Under Florida taw, e-mail addresses are public records. if you do not want yours e-mail-address'released'itt response to a public records request, do not send electronic mail to this entity. Instead, contatt ‘office’ by phoné or in’ wrth ing. EXHIB http://www.clerk-17th-flcourts.org/bccoc2/pubsearch/case_summary.asp?COCE02925348... arte qhos MMISIT Sew PASE Home | Online Services | FAQ | Fine Payments | My Account | Public Search | Downloads | Premium Search | Case Summary Broward County Case Number: 05014942CF10B State Reporting Number: 062005CF014942B88 Court Type: FELONY Case Type: FELONY Incident Date: 09/07/2005 Filing Date: 10/14/2005 Court Location: BROWARD COUNTY CENTRAL . 1 COURTHOUSE Case Status: DISPOSITION ENTERED Case Parties SS a a Co GL aC CO Pr prof poser Key Dates - Future Scheduled Events There is no key date information available for this case. Counts Select [> Filed On |Fil Count ount Status Statute Statute Description tiled On ile BRO FXXD8175682 CRIM USE OF PERSONAL ID INFO 10/14/2005 | SHE Related Cases Related Case Case T Number a ype 05014943CF10A TRANSFER - COMPANION Please click the "Pay Fine/Fee” button to check if fines or fees are due. * Click Here for clarification of the case status. Additional Text Case Detail NOTE: Selecting the "Case Detail" button will deduct one unit from your account. Perform Another Search [8 Broward County Clerk of the Courts Contact Us Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing. http://www.clerk-17th-flcourts.org/bccoc2/pubsearch/case_summary. asp?Coc 25348... 7 a3 (2008 MHISIT_WO RAG . SAU BUUALNG? BOUSUL166T TOL STATE. OF FLORIDA VS. COURT CASE: 05014942CF108 CSOT fo CASE NO. ——______ jusge Sod J MURPHY OFFENSE REPORT NO. VICTIM IMPACT STATEMENT [F.S.921.143 (1)(B)] wi CT NOTICE: THIS STATEMENT, PAGES 1-2, WITH ATTACHMENTS, IF ANY, SHALL BE FILED WITH THE SENTENCING COURT. FAILURE TO RETURN THIS DOCUMENT WITHIN THREE (3) DAYS MAY RESULT IN THE INABILITY TO OBTAIN COURT-ORDERED RESTITUTION. THIS STATEMENT MUST BE SIGNED (ON PAGE 2) IN THE PRESENCE OF A NOTARY PUBLIC. A. VICTIM DATA a, Sa ic 1. Victim's Full Name: Ruts Geta MtLEnzi€g Ron NOT Address: ij g ‘AST we OE City, State, ZIP: TOW GSS Home Phone: (Sb\) Ue io Work Phone: ( ) 2. Friend / Relative where you can be reached: Full Name: and a ees Avenue Address: \Q Ou WOES" VEN City, State, ZIP: TEEROLE PANES, fr DBGz __ Home Phone: (C{gy ) US\- { Work Phone: {SY ) Us > - SESS B. INJURY OR DEATH Did the victim require medical treatment for injuries that resulted from this incident? P<] No (go to the next section) [ ] Yes (complete the following): Doctor’s name: Hospital: List injuries: Cost of medical care to date: __ . ~ Do you expect more medical expenses? [ ] No { ] Yes If the victim is deceased, please list funeral and burial expense: §. Will your insurance pay for any expenses? [ ]No [ ] Yes Did you file a claim? [ ]No [| ] Yes If Yes, Claim # Have you been reimbursed? [ ] No [ ] Yes If so, how much? If you expect to be reimbursed in the future, how much? Name of Insurance Company: Op Ha 12 AYR BU | Address: City: State: Zip: : Telephone: ( ) Agent: ' Policy Number: Deductible: Have you filed a claim with the Crime Victim Compensation Fund? [ ] No [ ] Yes Claim # :. PROPERTY LOSS OR DAMAGE (House, Vehicle, Personal Property, etc.) Please list property that has been lost or damaged as a result of this incident. (Use additional pages, if necessary.) LOST (L) / DAMAGED (D} PURCHASE REPLACEMENT COST OF REPAIR IvreM ween Lor D ) PRICE DATE OF PURCHASE cost (IF DAMAGED) DON OOM aT an Pacsase “Or PLOPATY Co $3500 $ 2SCO "OB weer ATI PAPE) REA MATE DOARL AUNT RBNOn AWM Zs What property is currently in the custody of the Police or Sheriff's Department? =V 9/96 . FZ a VA001a MENT i ORIGINAL - CLERK EXHI2'T 7 _eace YF STATE OF FLORIDA VS _ALE&K(=; GeAnms CASE NO. OSVINT4 -T 16 - Will any items be covered by insurance? ~X] No [ ] Yes Did you file a claim? [ ] No [ ] Yes If yes, Claim # Name of Insurance Company: Address: City: : State: Zip: Telephone: ( ) Agent: Policy Number; _ CCC«é@M @elCtibS ew: If you have already been reimbursed, how much did you receive? Do you expect to be reimbursed in the future? [ ] No [ ] Yes How much? D. LOST WAGES . tf you lost-income because of the crime, please complete the following: Occupation/Job Title Number of days missed from work. Take home earnings for one day Employer: Supervisor: Address: City: State: Zip: Phone ( ) E. STATEMENT OF VICTIM/REPRESENTATIVE: 1) Please state how the crime has affected you and your family in terms of the hardships and inconveniences you have encured, as well as the emotional impact of the crime. __ aGue ; TIS HES CAUSEQ EMORNOw STRESS, StsEPSS ants NG AWATS BRO MeN a TE TMOUGAT OF SENG GOCRSET Be DOIG [S SICICENING- Muy {BD AWD Maar Hey Mor = > t CIMRENTENED BY THAT UNCERIRAIT 2) | would recommend the following case disposition (sentence): DX] Probation [ ] Prison Sentence [ ] Probation with Restitution [ ] Maximum Prison Sentence [ ] Other [ ] No Recommendation THIS STATEMENT MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC. This statement is subscribed and affirmed as true by the Affiant, under the penatfy of perjury. 02-19- 20m, Lead bia, Date Signed Signature of Victim or Representative STATE OF FLORIDA COUNTY OF WeRD Sworn to (or affirmed) and subscribed before me this ih day of FEBRuANY , 2006 , by Bul MAERUE ROP PRINT, T STAMP NAME OF NOTARY Personally known or Produced Identification Type of identification Produced nithi%6 SE Sixth St., Ft. Lauderdale, FL 33301 Telephone: (954) 765-4133 ° [Self-addressed envelope enclosed for your use] REV 9/96 a G £0 VA001b “CLERK nnn Es WT pl en ACE Sd

Docket for Case No: 09-001761PL