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<br /> 124 Contract Forms RFP—No.19-07-02 RFP—No.19-07-02Contrite Forms
<br /> 1 125
<br /> marten verse Wan an an=W190s agreend.WWI be.pine facie'Casa let one meant
<br /> hnbdsaarophna
<br /> mrvrpsrwrd a.pdKA Pawlnrywnomsuonmlyf
<br /> nfb0rraendWrciw tMa)defperdgalmre>ehmns OershW ataePUBLIC•ENTITY—CRIMES
<br /> Carel tsar fawn,
<br /> mneldered an alToMato
<br /> UM
<br /> ,,,,••••a- ...::,n
<br /> • ..P!e».,.n 11.5, I abler tan Nat a"Perwf as defiled in Para 7.17.733 04(e).Florida Stables.'rrean any edea
<br /> SWORN STATFNCNf PURSUANT TO S[CTION 2x7.133(3 'pilon a dairy argent:. ed under to bas d any Hale a s the09 United Bean oris Na on 0 power b
<br /> FLORIDA STATORS.ON PUBLIC ENTITY CRINES 1(a) enbr ate a boding Genesee and Mich Sidi a applies to Did on Catenate for the;coition d goods or
<br /> services let by a public Mity,or which otherwise transacts or apptin to transact besieis with a pudic
<br /> entity. The tam'perscne•bake=.those officers.'directors,eaeepaiyea partners,Ylrelabers.
<br /> PUBLIC parr',CRIMES employees,marroaa,aia.13"3 wmo s.i hca,n niso..mM a.rya air. _ - -
<br /> Puwrad to dM provisions o oe agiaph(21(i)d Section 257.133.Freida Sae=ties-•A pawn ea=Mat 11.5. Bastion hdormMim and belief.Um'stammers widen I hMe marked below is tree le 0101800 IO to entity
<br /> who his been placid en to oonolnbd Janda list/aewieg a conviction rr a pubic entity Crime may not Luba%ssubmittingInb sw0m statement(aldete*TIM staterlent apples.) -
<br /> ea melee an Contract vlee any 90006 arsenate b Ru
<br /> • be entity,Flay n01 warn a Bid on a Centred vet•
<br /> New entity Ice the con1px:Onn or tepee Of a pudic taking or public WRIn.•00r not Sub=Deem rises of Y._ Neither the amity submittingr,any hg an sworn statement. nory Es officeis.Oeeclas,axeai Nes,saber&
<br /> Beat property to a peke entity,mrob
<br /> may not be awaa4 palosa 1Verk n w,a Canawake,Sob{entriesii.a shareholders,.mpbyees,,nw0uen,oe'
<br /> Comulbnt Wer a Contract with any pubic'0may,and May not transact warms with sry.p iota soy N wase, wenn an rico are adof b the management cane d the subsequent
<br /> to Ju dry.
<br /> a dr thaandd annum ConQofy Two d Sac 287.077.FS lotefts y W months from the Cats d Ming pica an ;989.
<br /> d to entity has been WDad with and convicted d•poYc entity cane subsepwnt b Jdy 1.
<br /> oro 001oO1tedwlani kir. - -. - - �1 _ ..
<br /> TM3 FORM MUST BE SIGNED AND SWORN TO W THE PRESENCE OP A NOTARY PUBLIC OR OTHER _ The slily enarneb ng Strew sbtamdA crane or mare d Its takers,Oreganoexeaalrea.'partners.
<br /> OFFICIAL AUTHORQED TO ADMINISTER OADM. - ' shareholders,araloyees.members.or agents Liao ars cave b the ma sgemere_d the amity,a en
<br /> affiliau''od the entity cis neer.r.nargea with and cony-EW d a puke entity sine Meg:Ortm o Jay 1,
<br /> 11.1, 7rss Mom stamna art Is eaanlited to Co of Sum;rats Beady �_I/\ 1989.
<br /> .�.....a.W_AAA ����1Z ... - __ \'_ Tme r+ay 009090b9 N6 sworn atatana4 a«M a oars d b dkms.O e00I.asaar0.00.Osiers.
<br /> shareholders.nn ioyeas.members.ce agents*Ma ire active in nM management of the entity.a an
<br /> 'for _A pcisb / •C'.rp-floe affiliate or Use entity los been charged WM and convicted of a I�entad CAM 0Oaap-ent b Aly d.
<br /> 'e.e.e a.m""�'r"^......,-- .I �//�� ,/- 1988. However.•Nae his been a subsequent proaemrg before a Hearing Offiw of to Stab d
<br /> whose Waneai address b: I 0 L lni- I N F-aNLI( T i Fonda.Divitian a AdmbistrathR iitangs aM tlb Find ONa mserW by Ne'Hesin9 ORa;er d tlr
<br /> . G�'_ �,"`"" _ Sob d Fbrida.Dirlsan d n artiaatrat'we Haacrgs am ata Fe01 Ords'en4red byte/lasing ORrtv
<br /> lY)om.ii fi tic#-h_ j313 1 ^ debrmned that a was not b he p!rtle interest to place the entity subnatlgg Mb Man Malan 1 on to
<br /> coorided rend«gat(A0ch a copy d the anal nide.)
<br /> and(teppocabb)I.Pedant Engloya bentlf®Bon nonoe(FEIM Ii ^SDS III �yL7I UNDERSTAND THAT THE SUBMISSION OF 77AS FORM TO THE CONTRACTING OFFICER FOR THE
<br /> (t tla•aaXy Had no FEW,ineald0 Ne Socid_Satuiy Number a the individual thio swan PUBLIC ENTITY IDENTIFIED IN PARAGRAPH I1.1(ONE)ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND,
<br /> smemen1 - - - ') THAT THIS FORM IS VALID TROUGH DECEMBER 3/OF THE'CALENDAR YEAR W WHICH IT IS FILED.,I
<br /> 112- !understand tel a'puefc entity crime as defend In paragraph 287.137(1)(8),Fiends Staub&means a
<br /> ALSO,UNDERS7ANDTHAT I AM REOIxRED TO*WORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO
<br /> or C
<br /> viobtial d eery stare a federal law by a parson with respect to and amply retaW o MM bansatsonb "A'CONTRA FOR W EXCESS OF 711E THRESHOLD AMOUNT PROVIDED W SECTION 287.017,'FLORIDA
<br /> business with dry pu0lp,emty a with an agercy'a pa0cal subelNidpn d dry oNa'sob a with ON STATUTES. CATEGORY TWO OF ANY,CHANGE W THE INFORMAT1011 CONTAINED IN THIS FORA.
<br /> indudb9•out et emibd m,any Bra Contract for goods•a serhoes o be polled to ay' _ _
<br /> public entry or an egenoy;«poetical eu94Hbion d ay 011e stab el to United States and Swaney .BY, - '
<br /> United States,
<br /> meant,fraud.heft bnbay,tdha no.raketeaa^G comOrscy a nmta i oasrepresenta*a. '_- GAAA'-
<br /> ( P U , ,-
<br /> 111 I atlerstand tml'mnvicteC a'cenvidien•as defined a Pars.487 133(1)10),;Fbada'Statutes,mem a ... -
<br /> findig of gado,a-conviction Of a public seely dare,with a*Dai!en adluotatioq;d 80iR in-any (perNara) ft:6ex -- - -
<br /> lederal'or sole Iran court d record relating to Wr9es bright by adamant d idormwon after July I. 1 r
<br /> 1959.as a result of a goy inn*.Mn-}%tial,a entry of a plea of 9u• lny.a rob waeMae. Ride/ /1 1
<br /> . O �,.rli: Sworn ioacidaudsariWdbefoiemaUu.l(1 day of -AvgJS'1 ion.0,
<br /> ''11.1, IunderitaM that an'.161e'is Meed in fans 207t3i(18in Florida Slaws.. d. -
<br /> 0) pe4eceeior Or successor d.pawn convlWd dpublicpublice0aty olnie;a •
<br /> •
<br /> (AFFIX NOTARY STAMP HERE) -
<br /> 4. Ariy entity under tie mad d any natural person nisi p aWi�In the rmaed 5
<br /> gemem ro entity
<br />• .'aid who ata =Nil=bee =Nil=M public entityaentity amne;,•TlM.brm'affiliate includes Sablefom
<br /> oia.
<br /> '1#'4,. 'AIInEwM«ae.. SWivaa: . .iIkC�L f', -
<br /> drectors'exec+A0rs,partners.shareiaaders,erntawem,mNmb1s,Cru.pante vac Ira actva b ." � - -
<br /> to frbna 4nnnd of in awe,-TM ownership 5 one Paeans of snares cor 5b90*9 a wnb?Sk 0 ,a.rw,a,l,�,s.nw _ 1
<br /> taereol in seethe De!M0.«a P.a01iq o1 pdpnMmt a income among peraartswen ata for fah • �rww - off FrodiceO ldard5)cab^ 'J.'ei. .\1 C 21154' -
<br /> - • • Perwoly Known
<br /> se.slR>wa - —_-
<br /> 000000 <Rlai.v! l.cealR CRI.TIv O
<br />
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