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<br />6. Based on information and belief, the statement which I have marked below is true in relation to
<br />the entity submitting this sworn statement. [Indicate which statement applies]
<br />
<br />Neither the entity submitting this sworn statement, nor any of its officers, 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 with and convicted of a
<br />public entity crime subsequent to July 1, 1989.
<br />
<br />The entity submitting this sworn statement, or one or more of its officers, 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 with and convicted of a
<br />public entity crime subsequent to July 1, 1989.
<br />
<br />The entity submitting this sworn statement, or one or more of its officers, 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 with and convicted of a
<br />public entity crime subsequent to July 1, 1989. However, there has been a subsequent
<br />proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings
<br />and the Final Order entered by the Hearing Officer of the State of Florida, Division of
<br />Administrative Hearings and the Final Order entered by the Hearing Officer determined that it
<br />was not in the public interest to place the entity submitting this sworn statement on the convicted
<br />vendor list. [attach a copy of the final order]
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR
<br />THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY
<br />ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN
<br />WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC
<br />ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT
<br />PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANGE
<br />IN THE INFORMATION CONTAINED IN THIS FORM.
<br />
<br />Sworn to and subscribed before me this
<br />
<br />fDlb day of
<br />
<br />
<br />,2{[jj
<br />
<br />Personally known
<br />
<br />/
<br />
<br />Public - State of ~
<br />
<br />OR Produced identification
<br />
<br />(Type of identification)
<br />
<br />MtrrmiSSion expir s,:2
<br />
<br />
<br />(Printed typed or stamped
<br />commissioned nam~i1to\ijt~JY public)
<br />1\0'" '.~': t'IJBU.C - S'fATE Valencia
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<br />n~~. i~ ~Com,l1\lS~lO~ ~D~6, 2011
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<br />"I,,,..,." . nl) !~'lJ~~'HC BON ~.,\,l 00#
<br />>>OND!:.D 111
<br />
<br />
<br />05/08 Final Version
<br />
<br />00402-2
<br />
<br />05-4893
<br />
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