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<br />.
<br />
<br />.
<br />
<br />.
<br />
<br />executives, partners, shareholders, employees, members, and agents who are active In
<br />management of any entity.
<br />
<br />6. Based on information and belief, the statement which I have marked below is true in a relation to
<br />the entity submitting this sworn statement. (Please indicate which one (1) of the following three
<br />(3) statements is applicable.)
<br />
<br />_ (1) 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 management
<br />of the entity, or any affiliate of the entity has been charged with and convicted of a public entity
<br />crime within the past 36 months.
<br />
<br />_(2) 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 management
<br />of the entity, or any affiliate of the entity has been charged with and convicted of a public entity
<br />crime within the past 36 months.
<br />
<br />_(3) 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 management
<br />of the entity, or agents who are active in management of the entity, or any affiliate of the entity has
<br />been charged with and convicted of a public entity crime within the past 36 months. However, there
<br />has been a subsequent proceeding before a Hearing Officers of the State of Florida, Division of
<br />Administrative Hearings and the Final Order by the Hearing Officer determined that it was not in the
<br />public interest to place the entity submitting this sworn statement on the convicted vendor list.
<br />(Attached is a copy of the final order.)
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING
<br />OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH I (ONE) ABOVE IS FOR
<br />THE PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31
<br />OF THE CALENDAR YEAR IN WHICH IT IS FILED AND FOR THE PERIOD OF THE
<br />CONTRACT ENTERED INTO, WHICHEVER PERIOD IS LONGER. I ALSO UNDERSTAND
<br />THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A
<br />CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017,
<br />FLORIDA STATUTES FOR THE CATEGORY TWO OF ANY CHANGE IN THE
<br />INFORM~ TION -Cill): ~INED IN THIS FORM.
<br />
<br />~K/~ Bernard Zyscovich, AlA
<br />SIGNATURE OF AFFIANT (Printed or Typed Legal Name of Affiant)
<br />
<br />State of FL
<br />
<br />County of DADE
<br />
<br />Sworn to and subscribed before me this 11/1.- day of
<br />
<br />J3~lWrd 21;;fM/V/c4-...
<br />l/se-fl--L ;v!ar(~ S/Vr/OC--
<br />
<br />6.ep/&~, 2007 by
<br />
<br />Notary Seal:
<br />
<br />Notary's Name Printed, Stamped or Typed
<br />
<br />Personally Known: ~
<br />
<br />Identification Produced
<br />
<br />or Produced Identification
<br />
<br />J'II / ff
<br />/
<br />
<br />"{;;'::";j;;:,, USETIE MARIE SIERRA
<br />~l:'" ''';
<br />f:: . ~;~ MY COMMISSION' DO 590520
<br />~\ .W EXPIRES: September 4,2010
<br />"!;Jt:Ri( ,'fr,"f>' Bonded Thill Notary Public UnderwriteB
<br />
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