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<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 /> a 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 /> 0 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 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 AMO T PROVIDED IN SECTION 287.017, FLORIDA
<br /> ® STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN E INFORMATION CONTAINED IN THIS FORM.
<br /> ® By: \I\alVigil
<br /> (Signature) I
<br /> ,
<br /> ® William G. Benson, C.P.A.
<br /> ® (Printed Name)
<br /> Managing Partner
<br /> ® (Title)
<br /> ® Sworn to and subscribed before me this 30 day of c- , 20 is , by
<br /> ® (A \ito..... v R-e-nSn
<br /> ® (AFFIX NOTARY STAMP HERE) Age 4 Cel—e,
<br /> ® .•w KAITLINF.CHUBECK Signature: Notary Public —State of Florida
<br /> +` C MY COMMISSION YfFF234866 j,t;�t,, n h-. 003bec_k
<br /> EXPIRES:MAY 27,2019 Print or Type Commissioned Name
<br /> ® 1 �"P &maw 6irough 1st State Insurance
<br /> ® Personally Known X OR Produced Identification
<br /> ® Type of Identification Produced
<br /> ® ion99e 3of7
<br />
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