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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 />RXX Neither the entity submitting this sworn statement, or any of its officers, directors, executives, <br />partners, shareholders, employees, members, or agents who are active in the management of the entity, nor <br />any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July <br />1, 1989. <br />The entity submitting this sworn statement, or one or more of its officers, directors, executives, <br />partners, shareholders, employees, members, or agents who are active in the management of the entity, or <br />any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July <br />1, 1989. <br />The entity submitting this sworn statement, or one or more of its officers, directors, executives, <br />partners, shareholders, employees, members, or agents who are active in the management of the entity, nor <br />any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July <br />1, 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 <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 />1 UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER <br />FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH ONE (1) ABOVE IS FOR THAT PUBLIC <br />ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEIihER 31 OF THE <br />CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO <br />INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE <br />T14RESHOLD AMOUNT PROVIDED IN SECTION 287.017", FLORIDA STATUTES FOR <br />CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. <br />(Sig tore) <br />Sworn to and subscribed before me this day of ,19 <br />Personally known'} <br />OR Produced identification <br />(Type of Identification) <br />Form PUR 7087 (Rev. 06/18/92) <br />u <br />Notary Public -State of <br />My Commission expires <br />Florida <br />(Printed, typed, or stamped <br />commissioned name of notary public) <br />••r:� VILMA RIVERA <br />MY CO ;.. MMISSION N CC 711040 <br />'a EXPIRES: Jamiaryr 26, 2002 <br />earned Thru Notary N* unftmt s <br />2 of 2 <br />