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<br />- <br /> <br />A TT ACHMENT E <br /> <br />JAGIBYRNE GRANT ADMINISTRATION <br /> <br />MIAMI-DADE COUNTY AFFIDAVITS <br /> <br />The contracting individual or entity (governmental or otherwise) shall indicate by an "X" all affidavits <br />that pertain to this contract and shall indicate by an "N/ A" all affidavits that do not pertain to this contract. All <br />blank spaces must be filled. <br /> <br />The MIAl\.1I-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT; MIAMI-DADE COUNTY <br />EMPLOYMENT DISCLOSURE AFFIDAVIT; MIAl\.1I-DADE CRIMINAL RECORD AFFIDAVIT; <br />DISABILITY NONDISCRIMINATION AFFIDA V IT;. and the PROJECT FRESH ST ART AFFIDAVIT shall <br />not pertain to contracts with the United States or any of its departments or agencies thereof, the State or any <br />political subdivision or agency thereof or any municipality of this State. The MIAMI-DADE F AMIL Y LEAVE <br />AFFIDA VIT shall not pertain to contracts with the United States or any of its departments or agencies or the <br />State of Florida or any political subdivision or agency thereof; it shall, however, pertain to municipalities of the <br />State of Florida. All other contracting entities or individuals shall read carefully each affidavit to determine <br />whether or not it pertains to this contract. <br /> <br />I, NOem~N S. !;de Icup <br />Affiant <br /> <br />, being first duly sworn state: <br /> <br />The full legal name and business address of the person(s) or entity contracting or transacting business with <br />Miami-Dade County are (Post Office addresses are not acceptable): <br /> <br />CDS -0784rc47 <br />Federal Employer Identification Number (If none, Social Security) <br /> <br />C 11"'1 G ~ Sl.)() r"I 'f J::hLe-s B e<:lch <br />Name of Entity, Individual(s), Partners, or Corporation <br /> <br />Doing Business As (if same as above, leave blank) <br /> <br />J 8070 La I( INS AVE . SUyl () y rS. LES B eOtch I 1= l- '33 l Co G <br />Street Address City State Zip Code <br /> <br />N I A 1. MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT (Sec. 2-8.1 of the County Code) <br /> <br />1. If the contract or business transaction is with a corporation, the full legal name and business address <br />shall be provided for each officer and director and each stockholder who holds directly or indirectly <br />five percent (5%) or more of the corporation's stock. If the contract or business transaction is with a <br />partnership, the foregoing information shall be provided for each partner. If the contract or business <br />transaction is with a trust, the full legal name and address shall be provided for each trustee and each <br />beneficiary. The foregoing requirements shall not pertain to contracts with publicly traded <br />corporations or to contracts with the United States or any department or agency thereof, the State or <br />any political subdivision or agency thereof or any municipality of this State. All such names and <br />addresses are (post Office addresses are not acceptable): <br /> <br />Full Legal Name <br /> <br />Address <br /> <br />Ownership <br /> <br />% <br /> <br />% <br /> <br />% <br /> <br />lof5 <br />2. The full legal names and business address of any other individual (other than subcontractors, <br />material men, suppliers, laborers, or lenders) who have, or will have, any interest (legal, equitable <br />