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<br /> ® : . PUBLIC ENTITY CRIMES
<br /> IkeV ��•� City of Sunny Isles Beads070
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<br /> •r 1 o" Telephonry Isles 84.341;l,FL 33160
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<br /> (305)907-0606 Fax(335)949-3113
<br /> 0 SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a)
<br /> ® FLORIDA STATUTES,ON PUBLIC ENTITY CRIMES
<br /> ® PUBUC 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 aime 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 Sec. 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 PUBUC OR OTHER
<br /> 0 OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
<br /> O 11.1. This sworn statement/is submitted to City of Sunny Isles Beach
<br /> ® [rt l bmduare(roama n�a t�ie � }.� 1 � /�
<br /> for Idea}wleaa awm�ugmaeomat.•.aitrsl Orl ! (,l Iked.1 l/r d
<br /> ® whose business addr is:
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<br /> O and(if applicable)its Federal Employer Identification number(FEIN)is
<br /> ® (If the entity had no FEIN, include the Social Security Number of the individual signing this sworn
<br /> statement 2.l 5- k1S - 2tu4
<br /> ® 11.2. I understand 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 States and involving
<br /> ® antitrust,fraud,theft,bribery,collusion,racketeering,conspiracy,or material misrepresentation.
<br /> ® 11.3. I understand that"convicted"or"conviction"as defined in Para.287.133(1)(b), Florida Statutes, means a
<br /> ®
<br /> finding of guilt or a conviction of a public entity gime, 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 /> O 1989,as a result of a jury verdict, non jury trial,or entry of a plea of guilty or nolo contendere.
<br /> 11.4. I 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 crime;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 /> ® DEC wact 2a,2010 2of7
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