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<br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />I. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br />. <br /> <br />6. Based on information and belief, the statement which I have marked below is true in a relation <br />to the entity submitting this sworn statement. (Please indicate which one (1) of the following <br />three (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 <br />management of the entity, or any affiliate of the entity has been charged with and convicted of a <br />public entity 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 <br />management of the entity, or any affiliate of the entity has been charged with and convicted of a <br />public entity 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 <br />management of the entity, or agents who are active in management of the entity, or any affiliate of <br />the entity has been charged with and convicted of a public entity crime within the past 36 months. <br />However, there has been a subsequent proceeding before a Hearing Officers of the State of <br />Florida, Division of Administrative Hearings and the Final Order by the Hearing Officer determined <br />that it was not in the public interest to place the entity submitting this sworn statement on the <br />convicted vendor list. (Attached is a copy of the final 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 THE PUBLIC <br />ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE <br />CALENDAR YEAR IN WHICH IT IS FILED AND FOR THE PERIOD OF THE CONTRACT <br />ENTERED INTO , WHICHEVER PERIOD IS LONGER. I ALSO UNDERSTAND THAT I AM <br />REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN <br />EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA <br />STATUTES FOR THE CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED <br />IN THIS FORM. <br /> <br /> <br />Terry L. Holt <br />(Printed or Typed Legal Name of Affiant) <br /> <br />State of Florida County of Miami-Dade <br />Sworn to and subscribed before me this Gj day of <br />., {'VI I ,-- <br />f~ . n' ''f~~ <br /> <br />Nt nom MJhl h~ <br />Notary's Name Printed, Stamped or Typed <br /> <br />Dc+v6-e r <br /> <br />, 2007 by <br /> <br />Notary Seal: <br /> <br />Personally Known: ~ <br /> <br />or Produced Identification <br /> <br />",'~\:~'::;;'", MIRIAM MUHINA <br />/~m~ ~~~~~ Notary PUblic. State at Florida <br />~. . . ~ Commission ExpiIs Jun 14, 2009 <br />\~~ {t,l Commission'DD411079 <br />"l~ OF ~ ,to <br />'''"i.." Bonded by National AIIn. <br /> <br />Identification Produced <br />