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<br /> :I% PUBLIC ENTITY CRIMES
<br /> �I ` City of Sunny Isles Beach
<br /> `'y: 18070 Ct Avenue
<br /> *r v o°�o Sunny Isles Beady FL 33160
<br /> Telephone:(305)917-0606 Fax(305)949-3113
<br /> SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a)
<br /> FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
<br /> PUBLIC 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 crime 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 PUBLIC OR OTHER
<br /> OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
<br /> 11.1. This sworn statement is submitted to City of Sunny Isles Beach
<br /> by 1}1 ip s� t /� pi
<br /> for -7—kn.C2of, S zt i G� =i+C,
<br /> whose business address is:
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<br /> Ho 1 ly i 4,7D77cii FL ,33n/q
<br /> and (if applicable)its Federal Employer Identification number(FEIN)is los-/D S.z 81 D .
<br /> (If the entity had no FEIN, include the Social Security Number of the individual signing this sworn
<br /> statement: .)
<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 /> finding of guilt or a conviction of a public entity crime, 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 /> 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 /> LtcE,o£x 29.2010 2o17
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