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�SVp1NY IS�Fd <br />A. <br />.aSas.:+3 p <br />yF �9F' Ft09- <br />Oi suN �`a0 <br />STATE OF FLORIDA ) <br />COUNTY OFW69) <br />ANTI -KICKBACK <br />City of Sunny Isles Beach <br />18070 Collins Avenue <br />Sunny Isles Beach, FL 33160 <br />Telephone: (305) 947.0606 Fax: (305) 949-3113 <br />ANTI -KICKBACK AFFIDAVIT <br />I, the undersigned, hereby duly sworn and deposed say that no portion of this sum herein Bid <br />will be paid to any employees of the City of Sunny Isles Beach or its elected officials as a <br />commission, kickback, reward or gift, directly or indirectly by me or any member of my firm or <br />by an officer of the corporation. <br />The foregoing instrument wa acknowledged before me this day of <br />►,QCs `i' 20 by , 2 120 1= rWA0 [name <br />of person], as A)QT-ARPr>M:i/_ [type of authority), for <br />Adagg 65 a Lno3wi [name of party on behalf of whom instrument was <br />executed]. <br />AFFIX NOTARY STAMP HERE: <br />�,«• <br />111161101111110. "on" <br />�M 00r -+�rol son OM AN <br />a Coit7n W=fteemolar <br />Notary Pu li —State of Florida <br />&1A!)d9,QPQ V4492 <br />Print or Type Commissioned Name <br />Personally Known OR Produced Identification <br />Type of Identification Produced ilnA © ,,L9t Lt i C-Ost` <br />DECEMBER28,2010 <br />