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<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 />~ (I) 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 3 I 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 />FORM. <br /> <br />W~~~ <br />SIGNA TV E OF AFFIANT <br /> <br />Ward J. Friszolowski, AlA, Executive Vice President <br />(Printed or Typed Legal Name of Affiant) <br /> <br />, <br /> <br />State of ';j~-, County of PU1L(,~ . <br />Sworn to and subscribed before me this .;)/"JJ day of "7f{at..l <br />I <br /> <br />, 20 I 0 by <br /> <br />&0\.,~O-AVZ~ ~ <br />Notary's Name Printed, Stamped or Typed <br /> <br />Personally Known: )c <br /> <br />or Produced Identification <br /> <br />Notary Seal: <br />""~'>';;." CARRIANNE CLARK <br />/t ~.~~:~ MY eOMMISSION # DD715414 <br />:'-~f~~~~;' EXPIRES Sepiember 17,2011 <br />(40;; 139S1.~~ f.,3 FlandaNotarySef'iice.com <br /> <br />Identi fication Produced <br />