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FORMS & ATTACHMENTS
<br />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 />11.5. 1 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 />11.6. 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 />X Neither 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 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 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 11.1 (ONE) ABOVE IS F �ftBLIC ENTITY ONLY AND,
<br />THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF TH LENDAR YEAR IN WHICH IT IS FILED. I
<br />ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM PUBLIC ENTITY PRIOR TO ENTERING INTO
<br />A CONTRACT IN EXCESS OF THE —M)LD A NT PROVIDED IN SECTION 287.017, FLORIDA
<br />STATUTES, FOR CATEGORY TWO ANY, CHAN IN THE INFORMATION CONTAINED IN THIS FORM.
<br />By:
<br />(Si re
<br />Adolfo J. Cotilla, Jr.
<br />(Printed Name)
<br />President
<br />(Title)
<br />Sworn to and subscribed before me this 29th day of May 20 15 , by
<br />Adolfo J. Cotilla, Jr.
<br />(AFFIX O RY TA
<br />-'All F : �llCo l' encer
<br />COMMISSION i 194540 Signatur . No ry Py1� rc — Late of Florida
<br />EXPIRES: Janm 29, 2019 f/
<br />www.AARMOtARY.CON Print or Type Commissioned Name
<br />Personally Known OR Produced Identification X
<br />Type of Identification Produced Florida Driver's License
<br />1011M 3 of 7
<br />RFQ No. 15 -04 -01 1 ARCHITECTURAL DESIGN SERVICES FOR A NEW FACILITY AT 18080 COLLINS AVE. 1
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