|
<br />I-
<br />I.
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />
<br />,
<br />
<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 FOLRM.
<br />-+=iJ(!jo~ .
<br />. _J
<br />[signature]
<br />
<br />Sworn to and subscribed before me this
<br />
<br />n'V\ \
<br />\./\ day of ~I ry:-: , 20.cB
<br />~ 'L~ ~
<br />.}~~)( ~,..7 ~
<br />NotaBliC - State"'U r-\(y,oh
<br />
<br />My commission expires Or () ~l i90 In
<br />~ I -- I
<br />. C\ ( I -rC. ',I t ()}-(.=> () {';> ~_
<br />(Print d typed or stamped
<br />commissioned name of notary public)
<br />
<br />Personally known X
<br />OR Produced identification
<br />
<br />(Type of identification)
<br />
<br />",~~~L'f.?~" Marite Jimenez
<br />'Q'~'("
<br />~:{ Y;: Commission # DD548534
<br />-'1;"';-;"i{l-'..~: Expires June 19. 2010
<br />,~~.~~\" Bonded Troy Fain . Insurance Inc 800-385-7019
<br />
<br />05/08 Final Version
<br />
<br />00402-2
<br />
<br />05-4893
<br />
|