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• o • N Y/r<FI `SV T 1• �� CONFLICT OF INTEREST vi- I: • V City of Sunny Isles Beach 18070 Collins Avenue ® .3.—,—,--o,-000s, c Sunny Isles Beach,FL 33160 ® o. a� Telephone:(305)947-0606 Fax:(305)949-3113 • CONFLICT OF INTEREST STATEMENT • The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State Statutes. Proposers must • disclose with their Bids, the name of any officer, director, partner, associate or agent who is also an officer or employee of the City of Sunny Isles Beach or its agencies. 0 STATE OF FLORIDA • COUNTY OF Broward • BEFORE ME, the undersigned authority, personally appeared Francisco Costoya, Jr. , who was duly sworn, • deposes, and states: • 18.1. I am the President/Owner of Frank Costoya Architect. P.A. with a local office in 5230 S University Drive, St 103 and principal office in • same as focal Davie, Florida 33328 • 18.2. The above named entity is submitting a Bid for the City of Sunny Isles Beach, Bid No. 12-04-02 described c''.Architectural 8 Engineering Services The Affiant has made diligent inquiry and provides the information contained in this • Flans Only(CCNA) 9 Q ry Affidavit based upon his own knowledge. • 18.3 The Affiant states that only one submittal for the above Bid is being submitted and that the above named entity has • no financial interest in other entities submitting Bids for the same project. • 18.4 Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, participated in any collusion,or otherwise taken any action in restraints of free competitive pricing in connection with the entity's submittal for • the above Bid. This statement restricts the discussion of pricing data until the completion of negotiations if necessary and • execution of the Contract for this project. • 18.5 Neither the entity nor its affiliates, nor any one associated with them, is presently suspended or otherwise ineligible from participation in contract letting by any local, State,or Federal Agency. • 18.6 Neither the entity, nor its affiliates, nor any one associated with them have any potential conflict of interest due to any • other clients,contracts,or property interests for this project. • 18.71 certify that no member of the entity's ownership or management is presently applying for any employee position or e actively seeking an elected position with the City of Sunny Isles Beach. 0 18.8 I certify t••t n. member of e entity's ownership or management, or staff has a vested interest in any aspect of the City of Sunny Is!z.. Beac . • 18.9 In the event tha onfi t of i erest is identified in the provision of services, I, on behalf of the above named entity, will immediat:y notify the i I -.u. -ii:each. ® Dated thi �mj- I' a , . tofll , 2012 WAVVI Francisco Costoya, Jr. - President/Owner U AFFIANT r • r / Print or Type Name and Title © Sworn to and subscribed before me this 30 day of April 2012 ® 0 Personally Known X OR Produced Identification ; Type of Identification ` ® _ / l - C—fin\___ ® NOTARY PUBLIC STATE OF FLORIDA ® NOTARY PUBLIC-STATE OF FLORIDA r Jay C. Evans Commission#DD795436 . ' Expires: JULY OS,2012 ® BONDED Tn RD ATIAX IC RONDNG Co,LNC. O 0E0E848E828.2010 5 of 7 58