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e�SONNY !S�`�m •.
<br />-�y: PUBLIC ENTITY CRIMES
<br />" City of Sunny Isles Beach
<br />18070 Collins Avenue
<br />14!.*.F LOR�Q ybh Sunny Isles Beach, FL 33160
<br />or iuis ANv Telephone: (305) 947-0606 Fax: (305) 949-3113
<br />SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a)
<br />FLORIDA STATUTES; ON -PUBLIC ENTITY CRIMES
<br />PUBLIC ENTITY CRIMES
<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 on the convicted vendor list following a conviction for a public entity crime may not submit a
<br />Bid on a Contract to provide any goods or services to a public entity, may not submit 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 of 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 />11.1. This sworn statement is submitted toCityof Sunnv Isles Beach
<br />by6(40
<br />for AZ6&b.`i�� A4CI— 40M ft
<br />1pnni name ur entity sum ng swum statementl
<br />whose business address is:
<br />���Sa Zr/,�rT pi�i� �1G'1' /rti,r�i9.�►r 161
<br />and (if applicable) its Federal Employer Identification number (FEIN) is 34-0253240
<br />(If the entity had no FEIN, include the Social Security Number of the individual signing this sworn
<br />statement: )
<br />11.2. 1 understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means 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, any, 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, collusion,,- racketeering, conspiracy, or material misrepresentation.
<br />11.3. 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 July 1,
<br />1989, as a result of a jury verdict, non -jury trial, or entry of a plea of guilty or nolo contendere.
<br />11.4. 1 understand that an "affiliate" as defined in Para. 287.133(1)(a), Florida Statutes,, means:
<br />i�i.Ss'i :•tli t%i<.� .. „�1;i�;.!!' i:e uH .h2P ifin7�j,
<br />predecessor or successor of a person convicted of a public entity crime; or "'; , .:-; •.
<br />b.) Any entity under the control of any natural person who is active In #he' t anagemii 'ht" fi'the entity
<br />and who has been convicted of a public entity crime. The terrri`9 affiliate"'in"cludes 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 equipment or income among persons when not for fair
<br />DECEMBER28,2010
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