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FORMS AND ATTACHMENTS H &21)/,&72),17(5(67 City of Sunny Isles Beach 18070 Collins Avenue Sunny Isles Beach, FL 33160 Telephone: (305) 947-0606 Fax: (305) 949-3113 &21)/,&72),17(5(6767$7(0(17 The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State Statutes. Proposers must disclose with their Bids, the name of any officer, director, partner, associate or agent who is also an officer or employee of the City of Sunny Isles Beach or its agencies. STATE OF FLORIDA COUNTY OF 3$/0%($&+ BEFORE ME, the undersigned authority, personally appeared 0LFKDHO ' $YLURP, who was duly sworn, deposes, and states: IDmthe3UHVLGHQWof$YLURP $VVRFLDWHV,QFZith a local office in %RFD 5DWRQ )/ and principal office in %RFD5DWRQ)/. The above named entity is submitting a Bid for the City of Sunny Isles Beach, 5)4 No. described as:5)4 3URIHVVLRQDO VHUYLFHV. The Affiant has made diligent inquiry and provides the information contained in this Affidavit based upon his own knowledge. The Affiant states that only one submittal for the above Bid is being submitted and that the above named entity has no financial interest in other entities submitting Bids for the same project. Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraints of free competitive pricing in connection with the entity’s submittal for the above Bid. This statement restricts the discussion of pricing data until the completion of negotiations if necessary and execution of the Contract for this project. Neither the entity nor its affiliates, nor any one associated with them, is presently suspended or otherwise ineligible from participation in contract letting by any local, State, or Federal Agency. Neither the entity, nor its affiliates, nor any one associated with them have any potential conflict of interest due to any other clients, contracts, or property interests for this project. I certify that no member of the entity’s ownership or management is presently applying for any employee position or actively seeking an elected position with the City of Sunny Isles Beach. I certify that no member of the entity’s ownership or management, or staff has a vested interest in any aspect of the City of Sunny Isles Beach. In the event that a conflict of interest is identified in the provision of services, I, on behalf of the above named entity, will immediately notify the City of Sunny Isles Beach. Dated this _________ day of _____________________________________, 20. _________________________________ _________________________________ AFFIANT Print or Type Name and Title Sworn to and subscribed before me this _____ day of ______________________, 20. Personally Known ________ OR Produced Identification ________; Type of Identification _________________________ __________________________________ 127$5<38%/,&67$7(2))/25,'$ DECEMBER 28, 2010 3rd August Michael D. Avirom / President DaDaDaDateteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteteted this ___________________________________________________________________________________________________________ day __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ AFFIANT 3rd August ification ___________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________