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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 /> 11.5. 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 /> 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 /> /
<br /> Y 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 FOR THAT PUBLIC ENTITY ONLY AND,
<br /> THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I
<br /> ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO
<br /> A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA
<br /> STATUTES, FOR CATEGORY TWO OF AN CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.
<br /> By: •
<br /> (Signatu )
<br /> R t1 l R f-lf1S
<br /> (Printed Name)
<br /> R-
<br /> (Title)
<br /> ter Sworn to and subscribed before me this IP day of 4W-10451- , PO IS by
<br /> 2/k"4 N.Ws I
<br /> (AFFI- _ ._. _ .. .."
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<br /> W 81ENESES
<br /> • Notary Public-State of Florida F Signature: Notary P l"lic—State of Florida
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<br /> • = My Comm.Expires Jul 1.2018 i I"' ".Tril Ken.CS CS
<br /> %;o n • Commission# FF 138149 •
<br /> Print or Type Commissioned Name
<br /> Persona y nown •- =r:u e: dentification vet-
<br /> Type of Identification Produced tio.to• ilitAv.e.ks Li -0%-N
<br /> 10/1995 3 of 10
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