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O� SJNNY IS4FSR <br />y F <br />�YF D9J% FLOp\Q S,�r <br />Yo, SUN <br />STATE OF FLORIDA ) <br />COUNTY OF ) <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 />In <br />Title: <br />The foregoing instrument was <br />20_, by <br />of person], as <br />executed]. <br />AFFIX NOTARY STAMP HERE: <br />acknowledged before me this day of <br />(name <br />[type of authority], for <br />[name of party on behalf of whom instrument was <br />Notary Public — State of Florida <br />Print or Type Commissioned Name <br />Personally Known OR Produced Identification <br />Type of Identification Produced <br />7 of 8 <br />