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market value under an arm's length agreement, shall be a prime facie case that one person
<br />controls another person. A person who knowingly enters into a joint venture with a person who
<br />has been convicted of a public entity crime in Florida during the preceding 36 months shall be
<br />considered an affiliate.
<br />5. I understand that a "person" as defined in Para. 287.133(1)(e), Florida Statutes, means any natural
<br />person or entity organized under the laws of any state or of the United States with the legal power to
<br />enter into a binding Contract and which Bids or applies to Bid on Contracts for the provision of goods or
<br />services let by a public entity, or which otherwise transacts or applies to transact business with a public
<br />entity. The term "persons" includes those officers, directors, executives, partners, shareholders,
<br />employees, members, and agents who are active in management of any entity.
<br />6. Based on information and belief, the statement which I have marked below is true in relation to the entity
<br />submitting this sworn statement. (Indicate which statement applies.)
<br />XNeither the entity submitting this sworn statement, nor any of it's officers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in the management of the entity, nor any
<br />affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1,
<br />1989.
<br />The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in the management of the entity, or an
<br />affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 11
<br />1989.
<br />The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in the management of the entity, or an
<br />affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1,
<br />1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of
<br />Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer of the
<br />State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer
<br />determined that it was not in the public interest to place the entity submitting this sworn statement on the
<br />convicted vendor list. (Attach a copy of the final order.)
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE
<br />PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND,
<br />THAT THIS FORM IS VALID THROUGH �MBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I
<br />ALSO UNDERSTAND THAT I AM REQUI TO INFORM TI -It PUBLIC ENTITY PRIOR TO ENTERING INTO
<br />A CONTRACT IN EXCESS OF THE TH HO'D AMOUNIVROVIDED IN SECTION 287.017, FLORIDA
<br />STATUTES, FOR CATEGORY TWO OF /aN iJV
<br />E IN THE I ORMATION CONTAINED IN THIS FORM.
<br />By:
<br />(Signature)
<br />(Printed Name) ,DYES i!� Pi•'l
<br />(Title) i
<br />Sworn to and subscribed before me this day of 20.A, by
<br />(AF 1 C
<br />Notary Public au* a F
<br />Sydney Herren Signature: No ary Public t State of Florida
<br />i,N�%My commission 00 77 �/a
<br />Eapns 101041101 Print or TyiJe Comm ssioned Name
<br />Personally Known OR Produced Identification
<br />Type of Identification Produced
<br />3of12
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