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<br />6. <br /> <br />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 th~' 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 EXC~SS 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 />~ ' I <br /> <br />! [signature] <br /> <br />Sworn to and subscribed before me this <br /> <br />7th day of <br /> <br />JU/!4~~ <br /> <br />,. V ~ <br />Notary Public - State of --Floriria __ <br /> <br />Personally known (Robert Baer) <br /> <br />~ <br /> <br />OR Produced identification <br /> <br />\\\\\\tIlIlIIIJ,'" <br />~\~F\RA Y 'II/. <br />(Type of identif~~.....:t9/~ <br />S ...~\lIMISSIO~:.. ,~~ <br />~ . CJV 't'R,. .'?~ <br />~ ..~ ~1I\ 7'<'0 "t;o.. -;. <br />~*! ~~.~ ~ <br />- . ~. - <br />::z:: .... : = <br />- 0 0 IIDD R~ . * - <br />~~ a. wg8195 : ~ <br /><<;. ~ .'\. & .0 ~.-:::- <br />-~ ~o."A'J!IOdrnN ~..~S <br />~ Z~..""IIcUn4",",""o \)3' <br />~ 0'( ......... ~ ~~ <br />""II/IC, STATE o\,.}....... <br />111111/11"\1"" . <br /> <br />My commission expires 04==07 -2011 <br /> <br />Barbara Y. Rivera <br />(Printed typed or stamped <br />commissioned name of notary public) <br /> <br />05/08 Final Version <br /> <br />00402-2 <br /> <br />05-4893 <br />