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<br />6, Based on inforrnation and belief, the statement which I have marked below is true in relation to the entity
<br />submitting t0/8 sworn statement. [Indicate which statement applies]
<br />
<br />V Neither the entity submitting this sworn statement, nor 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 />
<br />The entity submitting this swom statement, or one or more of its officers, directors, executives,
<br />partflers, 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 ofa public entity crime subsequent to July
<br />1,1989.
<br />
<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 />I, 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 of the
<br />State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer
<br />deterrnined 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 ofthe final order]
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE
<br />PUBLIC ENTITY IDENTIFIED IN PARAGRAPH I (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY
<br />AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT
<br />IS FILED, I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO
<br />ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION
<br />287,017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION
<br />CONTAINED IN THIS FORM. ". , , ;<
<br />
<br />l ' I l/ 1, ,
<br />_____~/J ,A'/ /\ ' < (.{ /.(,/
<br />[signature]
<br />
<br />Sworn to and subscribed before me this i .k day of" . ..J 0\. Lei
<br />
<br />,2012.0
<br />
<br />Personally known
<br />
<br />.t/'
<br />
<br />OR Produced identification
<br />
<br />Notary Public - State of[:'/ VI' I cia
<br />
<br />~
<br />(P ~ ped or stamp~
<br />commis 'onedR8tTleoTnotary public) .
<br />,,"~'AIIt, Anabella Grohoskl
<br />/ftiS'A""'{~ Commission # 00426398
<br />;;,;, i;g Expires May 29, 2009 9
<br />'401f'', .. _385-701
<br />;':f.'IJ:'~~BondtdTro1Fa\n.'nsu'anc.,Inc.&lO
<br />Ililll\
<br />
<br />
<br />(Type of identification)
<br />
<br />Form PUR 7068 (Rev. 06/11/92)
<br />
<br />00402-2
<br />
<br />03-4138,C
<br />
<br />SIB
<br />
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