AFFIDAVIT FOR EXEMPTION AS A RETIRED PHYSICIAN
I, ________________________________________________, holder of a medical license number
_________________, valid from ________________ to ________________, issued by the State of
Florida, department of Health, do hereby swear and affirm that:
(a) I am not connected directly or indirectly with, or participate in, any
medically related occupation or field for compensation.
a. (Check One)
______ I am not currently employed by any person firm or other entity
including self-employment.
______ I am currently employed by:
____________________________________________________________
____________________________________________________________
____________________________________________________________
_______________
a. I currently reside in ___________________ County, Florida, and the following is
my current address and telephone number:
a. I acknowledge that this statement is given under oath for the express purpose of
obtaining an exemption from the payment of that certain assessment required
by Chapter 766, Florida Statutes, of all licensed physicians in the State of
Florida, and that this Affidavit is to be filed with the State of Florida,
Department of Health, and the Florida Birth-Related Neurological Injury
Compensation Association for purposes of obtaining such exemption, and
that materially false statements, in order to obtain this exemption, may result
in fine, suspension or revocation of my current medical license.
_____________________________ __________________________
Physician Signature Effective Date of Retirement
DATED this _______________ day of ________________________, 20______.
Sworn to and subscribed before me this __________ day of ______________ 20____ .
________________________________
NOTARY PUBLIC
My Commission Expires:
forms/retaff
