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<br />n
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<br />the provision of goods or services let hy a public entity, or which otherwise transacts or applies
<br />to transact business with a public entity, The term "person" includes those officers, directors,
<br />exccutives, partners. shareholders. employecs, members, and agents who arc active in
<br />management of any entity.
<br />
<br />6. Based on information and belief, the statement which I have marked bclow is true in a
<br />relation to the entity submitt ing this swom statcment. (Please indicate which one (1) of the
<br />following thrce (3) statements is applicable.)
<br />
<br />~ (1) Neither the entity sublnitting 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 cntity crime within the past 36 months,
<br />
<br />_____(2) The entity submitting this s\vorn statement, or one or more of its officers, dir.::ctors,
<br />executives, partners, shareholders, employees, members, or agents who are active ill 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 arc active in management of the entity, or any affiliate
<br />of the entity has been charged with and convicted of a public entity crime within the past 36
<br />months, However, there has been a subsequent proceeding before a Hearing Officer of the State
<br />of Florida, Division of Administrative Hearings and the Final Order by the Hearing Officer
<br />determined that it was not in the public interest to place the entity submitting this sworn
<br />statement on the convicted vendor list. (Attached is a copy of the final order.)
<br />
<br />I 'UNDERSTAND THAT THE SUBMISSION OF Tl-US FORM TO THE CONTRACTING
<br />OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH I (ONE) ABOVE IS
<br />FOR THE PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH
<br />DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED AND FOR THE
<br />PERIOD OF THE CONTRACT ENTERED INTO, WHICHEVER PERIOD IS LONGER. I
<br />ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY
<br />PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT
<br />PROVIDED IN SECTION 287,017, FLORIDA STATUTES FOR THE CATEGORY TWO OF
<br />ANY CIIANGE IN THE INFORMATION CONTAINED IN THIS FORM.
<br />
<br />dC2&4 ~ ~. . :t.1t:~1l~ r' ___ Laura;uc Lkhtmau, Prcs;dcu,
<br />SIGNA~(~' /. (Printed or Typed Legal Name of Affiant)
<br />
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<br />31
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