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<br />~ <br />~ <br />~ <br />~ <br />~ <br />~ <br />~ <br />~ <br />~ <br />~ <br />~ <br />:5! <br />::3 <br />:::3 <br />~ <br />:3 <br />~ <br />::3 <br />~ <br />~ <br />~ <br />::3 <br />:::!ij <br />~ <br />~ <br />~ <br />~ <br /> <br />SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a), <br />FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES <br /> <br />THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC <br />OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS. <br /> <br />1. <br /> <br />This sworn statement is submitted to~ity of Sunny Isles Beach, Florida <br />by Ed Dominguez ~ <br />[print individual's name and title] <br />SouIheestem Engineering eo..b~ M <br /> <br />for <br /> <br />[print name of entity submitting sworn statement] <br /> <br />whose business address is <br /> <br />1~ N..W. 98th Avenue, Hialeah Gardenl, FL 33018 <br />---~---- <br /> <br />and (if applicable) its Federal Employer Identification Number (FEIN) is ~ ~ &.s:i2'.....s::-z7 <br />(If the entity has no FEIN, include the Social Security Number of the individual signing this sworn <br />statement: .) <br /> <br />2. I understand that a "public entity crime" as defined in Paragraph 287. 133(1)(g), Florida Statutes, <br />means a violation of any state or. federal law by a person with respect to and directly related to the <br />transaction of business with any public entity or with an agency or political subdivision of any <br />other state or of the United States, including, but not limited to, any bid or contract for goods or <br />services to be provided to any public entity or an agency or political subdivision of any other state <br />or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, <br />conspiracy, or material misrepresentation. <br /> <br />3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1) (b), Florida <br />Statues, means a finding of guilt or a conviction of a public entity crime, with or without an <br />adjudication of guilt, in any federal or state trial court of record relating to charges brought by <br />indictment or information after July 1,1989, as a result ofajury verdict, nonjury trial, or entry ofa <br />plea of guilty or nolo contendere. <br /> <br />4. I understand that an "affiliate" as defined in Paragraph 287.133(1) (a), Florida Statutes, means: <br /> <br />1. A predecessor or successor of a person convicted of a public entity crime; or <br /> <br />2. An entity under the control of any natural person who is "active in the management of the entity <br />and who has been convicted of a public entity crime. The term "affiliate" includes those officers, <br />directors, executives, partners, shareholders, employees, members, and agents who are active in <br />the management of an affiliate. The ownership by one person of shares constituting a controlling <br />interest in another person, or a pooling of equipment or income among persons when not for fair <br />, market value under an arm's length agreement, shall be a prima facie case that one person controls <br />another person. A person who knowingly enters into a joint venture with a person who has been <br />convicted of a public entity crime in Florida during the preceding 36 months shall be considered <br />an affiliate. <br /> <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 with the legal <br />power to enter into a binding contract and which bids or applies to bid on contracts for the <br />provision of goods or services let by a public entity, or which otherwise transacts or applies to <br /> <br />Oct. 2007 <br />Form PUR 7068 (Rev. 06/11/92) <br /> <br />00402-1 <br />