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<br />e PUBLIC ENTITY CRIMES
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<br />City of sunny Isles Beach
<br />Ufa A 18070 Calffns Avenue
<br />#69iDr'rco4°�oa`'r S4nnyIsles Beach, FL 33180
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<br />OF sun ►� Telephone: (305) 847-000GI = (305) 048-3113
<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 Secs 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 />17.1. This sworn statement is submitted toCity ofi Sunny Isles Beach .
<br />by Yyr>EH ( 4104S. RZ�ig)er 9
<br />for cckrt - N eck e TNc
<br />[print name of entity Mubmwnqswom stetemenq
<br />whose business address is: Oblu Ave.. � �t9, , ,
<br />17- 38
<br />11,410 -Aft 6412DU S , FL 3,3ot o
<br />and (if applicable) its Federal Employer Identification nu
<br />statement:number (FEIN) is
<br />(if the entity had no FEIN, include. the Social Security Number of the individual signing this sworn
<br />.: _ •)
<br />11.2. 1 understated 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 Statesandinvolving
<br />antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentatlon.
<br />11.3. 1 understand that "convicted" or "conviction" as defined in Para. 287.133(1)(0), 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 />a.) predecessor or successor of a person convicted of a public entity crimes or
<br />b.) Any entity under the control of any natural person who is active in the management of the entity
<br />and who has been convicted of a public entity crime. The term "affiliate" 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 equipment or income among persons when not for fair
<br />OEOEMeER28,2010
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