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<br />5. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any <br />natural person or entity organized under the laws of any state or of the United States within the legal <br />power to enter into a binding contact and which bids or applies to bid on contracts for the provision <br />of goods or services let by a public entity, or which otherwise transacts or applies to transact business <br />with a public entity. The term "person" includes those officers, executives, partners, shareholders, <br />employees, members, and agents who are active in management of an entity. <br /> <br />6. Based on information and belief, the statement which I have marked below is true in relation to the <br />entity submitting this sworn statement. (Please indicate which statement applies.) <br /> <br />~Neither the entity submitting this sworn statement, nor any of its officers, direCtors, executives, <br />partners, shareholders, employees, members, or agents who are active in the management of the <br />entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime <br />subsequent to July 1, 1989. <br /> <br />_The entity submitting this sworn statement, or one or more of its officers, directors, executives, <br />partners, shareholders, employees, members, or agents who are active in the management of the <br />entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime <br />subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing <br />Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by <br />the Hearing Officer determined that it was not in the public interest to place the entity submitting <br />this sworn statement on the convicted 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 <br />ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR <br />YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THAT <br />PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD <br />AMOUNT PROVIDED IN SECTION 287.017 FLORIDA STATUTES FOR CATEGORY TWO OF ANY <br />CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. <br /> <br />(Signature) <br /> <br /> <br />/ <br /> <br />Swom to and ,"b'rbed bef... me thi, ~~ <br />Personally known t'.l o'R.JM.i'r~ S. ~~c.u ~ . <br />OR Produced Identification <br /> <br /> <br />~~4~ <br /> <br />day of ""DeUrv\~ <br /> <br />,20~. <br /> <br />Notary Public - State of fu>1'Lt oA <br />My commission expires $" {4f2-D n~ <br /> <br />(Type of Identification) <br /> <br />M ~~t.W ~crA-r1w(L <br />(Printed typed or stamped commissioned name of notary <br />public) <br /> <br /> <br />~y.v..tI\;;f <br /> <br />o.".Y PII"t. Notllry FI.Hlli6 fll1l1~ Il' f.18fi8~ <br />~ ~ 1: Mll\J(I(l11'l l)!rlilReYf <br />~ c: ~'I My Comm;lls,OIl gf1~1!ee7e <br />~? Of '" E!ipl(tI~ {)fJI(W~/jl 5 <br /> <br />20f2 <br />