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g. Based on information and belief, <br />sworn stathe ent. [Ind cat which have statement applies] <br />true in relation to <br />the entity submitting <br />Neither the entity submitting this sworn statement, nor any of its officers, directors, <br />ex , u ' es, 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, <br />directors, <br />executives, partners, shareholders, employees, members, h active <br />management of the entity, or ny affiliateothe entity has been a ged 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, <br />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 ere has with <br />been d convicted of a <br />public entity crime subsequent to July 1, 1989. However, <br />proceeding before a Hearing Officer of the State of Florida, <br />Division of Administrative Hearings <br />and the Final Order entered ad he Final Orderlent officer of <br />the officer Division it <br />Administrative Hearings <br />was not in the public interest final order] entity submitting this sworn statement on the convicted <br />c vendor list. [attach copy of the <br />I UNDERSTAND THAT THE SUBMISSION D INPARAGRAPH 1 FORM �BOVECI� FOR THAT OFFICER <br />BLIC ENTITY <br />FOR THE PUBLIC ENTITY IDENTIFIED <br />ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN <br />WHICH IT IS FILED. I ALSO UNDERSTAND CONTRACT INAEXCESS OF THE THRESHOLD AMOUNT <br />ENTITY PRIOR TO ENTERING <br />PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANGE <br />IN THE INFORMATION CONTAINED IN THIS FORM. �_._ --- ------- - - - -.� <br />s <br />[signature] <br />Sworn to and subscribed before me this day of 20 <br />Personally known <br />OR Produced identification <br />(Type of identification) <br />Notary PuPrIc - gt4te of <br />GL <br />MARIAUUANALATIEGUE My commission expires �- 2 <br />hrlY COMMISSION # DO 638227 <br />EXPIRES: June <br />' > ; g •• �,oF �: <br />9, 2411 c,4 ��j <br />jonoed Thru Notary Public Underwriters <br />� <br />Af" (Printed typed or stamped <br />commissioned name of notary public) <br />05108 Final Version <br />00402 -2 05 -4893 <br />