Laserfiche WebLink
<br />. <br /> <br />6. Based on information and belief, the statement which I have marked below is true in a <br />relation to the entity submitting this sworn statement. (Please indicate which one (I) of the <br />following 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 <br />a 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 <br />a 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 <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 Officers of the <br />State of Florida, Division of Administrative Hearings and the Final Order by the Hearing <br />Officer 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 THIS 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 <br />AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR THE <br />CATEGORY W F ANY CHANGE IN THE INFORMATION CONTAINED IN THIS <br />FORM. <br /> <br /> <br />T <br /> <br />Gus Berenblum, <br />(Printed or Typed Legal Name of Affiant) <br /> <br />State of Florid County of Miami-~ <br />Sworn to and subscribed before me this r. ~ da <br />~~*~If.t~... CynthIa D. Delgado <br />f~{ "~1COMMISSION#DD861425 ' <br />~,.;.: .....o~j' EXPIRES: FES, 15,2013 <br />'';<''OF fV _- <br />"'"11I"\\ WWW,MRONN01AAY.com Notary Seal: <br /> <br />Notary's Name Printed, Stamped or Typed <br /> <br />Personally Known: L- or Produced Identification _ <br /> <br /> <br />Identification Produced <br /> <br />RFQ #10-04-02 Professional Architectural Services I 34 <br />