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SWORN STATEMENT UNDER SECTION 287.133 (3) (a) FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. 1. This sworn statement is submitted with Bid, Proposal or Contract # For 2. This sworn statement is submitted by Whose business address is Federal Tax ID # 3. My name is entity above is (if applicable) and my relationship to the 4. I understand that a "public entity crime" as defined in Paragraph 287.133 (1)(g), Florida Statutes, means a violation of any state or federal law by a person directly related to the transaction of business with a public entity or with an agency or political subdivision of any other state , or with the United States, including but not limited to, any bid or contract for goods or services to be provided to any public entity or agency or political subdivision of any other state in the United States involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 5. 1 understand that "convicted" or "conviction" as defined in Paragraph 287.133 (1)(b), Florida Statutes, means a Finding of guilt or coniction of a public entity crime; with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment after Julv 1, 1989, as a result of a jury verdict, non -jury trial, or entry of Plea of ;,n►ilty or Nolo Contendre. G. I understand that an "affiliate" as defined in paragraph 287.133 (1)(a), Florida Statutes, means: 1. A predecessor or successor of a person convicted of a public entity crime; or 2. An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. I understand, that a "person" as defined in Paragraph 287.133(1)(c), Florida Statutes, means any natural person or entity organized under the laws of any state of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees, members and agents who are active in management of an entity.