Reso 2004-657 - Laserfiche WebLink

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6. Based on infonnation and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. [Indicate which statement applies] . Neither the entity submitting this sworn statement, nor any of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees. members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July I, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer detennined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. [attach a copy of the fmal order] I UNDERSTAND THAT THE SUBMISSION OF TillS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH I (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT TillS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND TIIA T I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN TillS FORM. ~D~ [Sign~ Personally known OR Produced identification ~ "".. Julys Q,_..v~ ~.. .~~.~- otaty Public - s>. e of , ~!.~= .3)_%.at.... :0- = ..~:~ ~t' ,. lI1::: ~ -,) . ::- ", G:.:- ~~....lYO .;::- My commissjon\.~1h1v ~ ~ .....)f.{ '% .s'J;4n':':~~.';"~~~~ "1".. ,1: OF f\.v.",'~ '/111111\'" (Printed typed or stamped commissioned name of notary public) Sworn to and subscribed before me this I 9 day of (Type of identification) Form PUR 7068 (Rev. 06/11/92) 00402-2 03-4122 SIB