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sot!NY/$1, <br /> 04 J <br /> ANTI - KICKBACK <br /> •l1 <br /> � : City of Sunny Isles Beach <br /> �' 18070 Udine Avenue <br /> •, o'�° •' Sump/Isles Beach,FL 33160 <br /> '' Telephone:(305)947-0606 Fax(305)949-3113 <br /> ANTI-KICKBACK AFFIDAVIT <br /> STATE OF FLORIDA ) <br /> COUNTY OF Broward ) <br /> I, the undersigned, hereby duly sworn and deposed say that no portion of this sum herein Bid <br /> will .be paid to any employees of the City of Sunny Isles Beach or its elected officials as a <br /> commission, kickback, reward or gift, directly or indirectly by me or any member of my firm or <br /> by an officer of the corporation. <br /> Jill <br /> By: Jason R. W': . - A�__ <br /> Title: President" <br /> • <br /> The foregoing instrument was acknowledged before me this 23rd day of <br /> August , 20 16 , by Jason R.Wells [name <br /> of person], as President [type of authority], for <br /> Jacey Investments,L.L.C. dlbia Elite Tent Company[name of party on behalf of whom instrument was <br /> executed]. <br /> AFFIX NOTARY STAMP HERE: <br /> 01.ikit!et imovlNotary Pulic—State of Florida <br /> ,�,:' .;:;.. LETICIA ROMAN Li-h <br /> : MY COMMISSION>3 FF244407 ei <br /> . <br /> a, EXPIRES June 25,2019 l <br /> oenS3 F „s. .sort � Print or Type Commissioned Name <br /> Personally Known V , OR Produced Identification <br /> Type of Identification Produced <br /> Decarset 28,2010 7 of 7 _,1 <br />