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<br /> �1,:i„, PUBLIC ENTITY CRIMES
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<br /> • City of Sunny Isles Beach
<br /> 18070 Collins Avenue
<br /> �'�'•s o/o+` ' Sunny Isles Beach,FL 33160
<br /> o. ,. o' Telephone:(305)947-0606 Fax:(305)949-3113
<br /> SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a)
<br /> i . FLORIDA STATUTES,ON PUBLIC ENTITY CRIMES
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<br /> ® PUBLIC ENTITY CRIMES
<br /> • Pursuant to the provisions of paragraph (2) (a) of Section 287.133, Florida State Statutes- "A person or affiliate
<br /> 0 who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a
<br /> Bid on a Contract to provide any goods or services to a public entity, may not submit a Bid on a Contract with a
<br /> O public entity for the construction or repair of a public building or public Work, may not submit Bids on leases of
<br /> real property to a public entity, may not be awarded to perform Work as a Contractor, supplier, Sub-Contractor, or
<br /> O Consultant under a Contract with any public entity, and may not transact business with any public entity in excess
<br /> • of the threshold amount Category Two of Sec. 287.017, FS for thirty six months from the date of being placed on
<br /> the convicted vendor list”.
<br /> ® THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
<br /> • OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
<br /> ® 11.1. This swore tement is submitted to City of Sunny Isles Beach
<br /> by —d7 S- A /f7F'2 — r/,-.l4r'I 7
<br /> O (pont and iduars name and title), /
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<br /> for A/U,f'Z (/ ?,54ci Ion LnC,
<br /> •
<br /> [print name entity submitting sworn statement[ r
<br /> whose business address is: •
<br /> / S!c J
<br /> c 7. GD C z_ Alf.e rig'e,
<br /> 410 36,414 /t'l1Arnt FG. •33/4-3
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<br /> • and(if applicable)its Federal Employer Identification number(FEIN)is %OS e)((2-2 - '?ô
<br /> (If the entity had no FEIN, include the Social Security Number of the individual signing this sworn
<br /> ® statement: .)
<br /> ® 11.2. I understand that a"public entity crime"as defined in Paragraph 287.133(1)(g), Florida Statutes, means a
<br /> • violation of any state or federal law by a person with respect to and directly related to the transaction of
<br /> business with any public entity or with an agency or political subdivision of any other state or with the
<br /> ® United States, including, but not limited to, any Bid or Contract for goods or services to be provided to any
<br /> public entity or an agency or political subdivision of any other state of the United States and involving
<br /> • antitrust,fraud,theft, bribery, collusion, racketeering,conspiracy,or material misrepresentation.
<br /> 11.3. I understand that"convicted" or"conviction"as defined in Para. 287.133(1)(b), Florida Statutes, means a
<br /> ® finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any
<br /> federal or state trail court of record relating to charges brought by indictment or information after July 1,
<br /> • 1989, as a result of a jury verdict, non-jury trial, or entry of a plea of guilty or nolo contendere.
<br /> OP 11.4. I understand that an"affiliate"as defined in Para.287.133(1)(a), Florida Statutes, means:
<br /> a.) predecessor or successor of a person convicted of a public entity crime;or
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<br /> ® b.) Any entity under the control of any natural person who is active in the management of the entity
<br /> and who has been convicted of a public entity crime. The term "affiliate" includes those officers,
<br /> 41 directors, executors, partners, shareholders, employees, members, and agents who are active in
<br /> Q the management of an affiliate. The ownership by one person of shares constituting a controlling
<br /> interest in another person, or a pooling of equipment or income among persons when not for fair
<br /> DECEMBER 2e,2010 2 of 8
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