|
<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 TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS
<br />FOR
<br />
<br />
<br />Ignacio Serralta, P.E.
<br />(Printed or Typed Legal Name of Affiant)
<br />
<br />State of Florida
<br />
<br />County of Miami-Dade
<br />
<br />./1-..J ~
<br />
<br />A - Pt0lb""UA-
<br />Notary's Name Printed, Stamr or Typed
<br />
<br />Personally Known: V or Produced Identification
<br />
<br />
<br />re me this 25th
<br />
<br />day of
<br />
<br />May
<br />
<br />,2010 by
<br />
<br />Notary Seal:
<br />
<br />Identification Produced
<br />
<br />.'~Y:~~4" RALPH AL8ERT ');-;:REDA
<br />--~'A"{'-:
<br />:.; " >..-. ,It'.' (' :');- 1",f,1 "'..-' "", '.i :',,",;'08450
<br />:.~ . \:~_. I,. ...".'1' .,-,,,...,~., ... .,"'"
<br />"~""o.'iJf:? '-. \';Plf~ES ,Jui~. <C,.' ,~1)12
<br />"'11'\'
<br />398-0153 FlondaNolaryServlce.com
<br />
|