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<br />transact business with a public entity. The term "person" includes those officers, dIrectors,
<br />executives, partners, shareholders, employees, members, and agents who are active in management
<br />of an entity,
<br />
<br />6. Based on infornlation and belief, the statement which I have marked below is true in relation to the
<br />entity submitting this sworn statement. [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,
<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 of the State of Florida, Division of Administrative Hearings and the Final
<br />Order entered by the Hearing Officer deternlined that it was not in the public interest to place the
<br />entity submitting this sworn statement on the convicted vendor list. [attach a copy of the final
<br />order]
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER
<br />FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC
<br />ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE
<br />CALENDAR YEAR IN \VHICH IT IS FILED, I ALSO UNDERSTAND THAT 1 AM REQUIRED TO
<br />INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE
<br />THRESHOLD j\MOUNT PROVIDED IN SECTION 287,017, FLORIDA STATUTES FOR
<br />CATEGORY TWO OF ANY CHANGE IN THE INFORMATION C NTA~NED IN THIS FORM.
<br />
<br />'"
<br />
<br />
<br />[signature]
<br />
<br />Sworn to and subscribed before me this J.Cb ~ 'h day of
<br />
<br />NO',f<2..m ber
<br />
<br />~
<br />
<br />~
<br />t_~
<br />c;/
<br />
<br />'[fC/
<br />
<br />~OnallY~
<br />
<br />.. - -......--'"
<br />
<br />- ----...
<br />,
<br />~
<br />
<br />OR Produced identification
<br />
<br />Notary Public - State of
<br />
<br />Fieri Jq
<br />
<br />(Type of identification)
<br />
<br />My commission expires G j (; / a. 0 I I
<br />
<br />'~lJ VQlel)t'~
<br />(Printed typed or stamped
<br />commissioned name of notary public)
<br />
<br />"'''''N::..,. DeJ
<br />4'!fIY.:.~ on Valentine
<br />!.:~A Commission DO 682437
<br />, ..; Expires June 6, 2011
<br />, '0' Bonded Thtu Troy FoIn Insurance ~7019
<br />
<br />Oct. 2007
<br />Form PUR 7068 (Re,'. 06/11/92)
<br />
<br />00402-2
<br />
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