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CITY OF SUNNY ISLES BEACH <br />PARKS/MEDLANS/RIGHT-OF-WAY MAINTENANCE <br />sworn statement on the convicted vendor list. (Attach a copy of the final order.) <br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING <br />OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1(ONE) ABOVE IS FOR <br />THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER <br />31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM <br />REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT <br />IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA <br />STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFORMATION <br />CONTAINED S FO . <br />By: <br />(Printed Name) <br />(Title) <br />Sworn to and subscribed before me this day of 06 f A4D_O / <br />ersonally known Z O %» <br />Produced Identifi�on�G .� �- Notary Public -State of <br />My Commission Expires /a� ao 3 (Type of <br />Identificati <br />Awv'& Madelyn a <br />(P ' p�, commissioned <br />nLUL .. cur Co., Inc. <br />:1D•ERS NAME:i C <br />