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4 � RA.
<br />PUBLIC ENTITY CRIMES
<br />City of Sunny Isles Beach
<br />T 16010 Collins Avenue
<br />•i "'•r,o+•e +' Sunny Wesesew,FL33100
<br />(3051907.4496 Far:i305)940-31 13
<br />SWORN STATEMENT PURSUANT TO SECTION 287,133(3)(a)
<br />FLORIDA STATUTES, ON PUBLIC ENTIITY CRIMES
<br />PUBLIC ENTITY GRIMES
<br />Pursuant to the provisions of paragraph (2) (a) of Section 287.133, Florida State Statutes - "A person or affiliate
<br />who has been placed oil the convicted vandor list following a Conviction for a public entity Grime may not submit a
<br />Bid on a Contract to provide any goods or services to a public entity, may not subrn]t a Bid on a Contract with a
<br />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 />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 Df 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 />1. This sworn statement is submitted la City of Sunny Islas Beooh
<br />by Kash' items,---
<br />Ipiraindividual's ri.m aid 011e]
<br />for DK Elrsrganq Seng M. LLC _-- -- --
<br />Ipiat rarnn orenG[y wUnilirm svau, slatvnsnl]
<br />whose business address is:
<br />aiove.erans bunewa-d. Sure St 5. WlrVp. LA n0008
<br />and (if applicable) its Federal Employer Identification number (FEIN}) is 1=
<br />(If the entity had no FEIN, include the Social Security Number of the individual signing this sworn
<br />statement: WA )
<br />2. f understand that a "public entity crime" as defined in Paragraph 257.133(1)(g), Florida Statutes, meals 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, sny 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, callusiun, racketeering, conspiracy, or material misrepresentation.
<br />3, 1 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 duly 1,
<br />1989, as a result of a jury verdict, nnn-jury trial, or entry of a plea of guilty or nolo contendere.
<br />4." I understand that an "affiliate" as defined in Para. 2$7.133(1)(0), Florida Statutes, means:
<br />a.) predecessor or successor of a person convicted of a pub lie entity crime: or
<br />b.) Any entity under the control of any naturat person who is active in the management of the entity
<br />and who has been convicted of a public entity crime. The, term 'af{iliale" includes those officers,
<br />directors, executors, partners, shareholders, employees, members, and agents who are active in
<br />the management of an affiliate. The ownership by one person of shares constituting a controlling
<br />interest in another person, or a pooling of equrprrrent or income among persons when not for fair
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