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r <br />i <br />0 <br />C <br />L <br />C <br />f <br />'J <br />P <br />Df <br />6. Based on information and belief, the statement which I have marked below is true in relation to <br />the entit submitting this sworn statement. [Indicate which statement applies] <br />Neither the entity submitting this sworn statement, nor any of its officers, directors, <br />executives, partners, shareholders, employees, members, or agents who are active in the <br />management of the entity, nor any affiliate of the entity has been charged with and convicted of a <br />public entity crime subsequent to July 1, 1989. <br />The entity submitting this sworn statement, or one or more of its officers, directors, <br />executives, partners, shareholders, employees, members, or agents who are active in the <br />management of the entity, nor any affiliate of the entity has been charged with and convicted of a <br />public entity crime subsequent to July 1, 1989. <br />The entity submitting this sworn statement, or one or more of its officers, directors, <br />executives, partners, shareholders, employees, members, or agents who are active in the <br />management of the entity, nor any affiliate of the entity has been charged with and convicted of a <br />public entity crime subsequent to July 1, 1989. However, there has been a subsequent <br />proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings <br />and the Final Order entered by the Hearing Officer of the State of Florida, Division of <br />Administrative Hearings and the Final Order entered by the Hearing Officer determined that it <br />was not in the public interest to place the entity submitting this sworn statement on the convicted <br />vendor list. [attach a copy of the final order] <br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR <br />THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY <br />ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN <br />WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC <br />ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THB McUNT <br />PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR CATEGO 0 OF ANY CHANGE`, <br />IN THE INFORMATION CONTAINED IN THIS FORM. / <br />Sworn to and subscribed before me this I— day of <br />Personally known ✓ <br />OR Produced identification <br />� A,'I A ULIAria. �anEruF <br />(Type of identification) '� }= MYCCr�i i�s��raor.;sao22� <br />r EXFIRES:Duna 9 2,111 <br />Bonded Tnru "imaq Pooli : Underwvhers <br />Final Version 6/07 00402 -2 <br />signature] <br />12007 <br />Not4 Pu 'A(- State of -R on dQ <br />My commission expires <br />Q 1'i ct L. la-k-,eone <br />(Printed typed or sta <br />commissioned name of notary public) <br />03 -4197 <br />