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<br />5. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any <br />natural person or entity organized under the laws of any state or of the United States within the legal <br />power to enter into a binding contact and which bids or applies to bid on contracts for the provision <br />of goods or services let by a public entity, or which otherwise transacts or applies to transact business <br />with a public entity. The term "person" includes those officers, executives, partners, shareholders, <br />employees, members, and agents who are active in management of an entity. <br /> <br />6. Based on information and belief, the statement which I have marked below is true in relation to the <br />entity submitting this sworn statement. (please indicate which statement applies.) <br /> <br />_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 <br />entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime <br />subsequent to July 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 <br />entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime <br />subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing <br />Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by <br />the Hearing Officer determined that it was not in the public interest to place the entity submitting <br />this sworn statement on the convicted vendor list. (attach a copy of the final order). <br /> <br />I UNDERSTAND THAT THE SUBMISSION OF TillS FORM TO THE eONTRAeTING OFFleER FOR <br />THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIe <br />ENTITY ONLY AND, THAT TillS FORM IS VALID THROUGH DEeEMBER 31 OF THE eALENDAR <br />YEAR IN wmeH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THAT <br />PUBLIe ENTITY PRIOR TO ENTERING INTO A CONTRAeT IN EXCESS OF THE THRESHOLD <br />AMOUNT PROVIDED IN SEeTION 287.017 FLORIDA STATUTES FOR eATEGORY TWO OF ANY <br />eHANGE IN THE INFORMATION eONTAINED IN TillS FORM. <br /> <br />(Signature) <br /> <br />Sworn to and subscribed before me this <br /> <br />day of <br /> <br />20_. <br /> <br />Personally known <br />OR Produced Identification <br /> <br />Notary Public - State of <br />My commission expires <br /> <br />(Type of Identification) <br /> <br />(printed typed or stamped commissioned name of notary <br />public) <br /> <br />20/2 <br />