|
JAN -09 -03 12:29PM FROM -CITY OF SUNNY ISLES BEACH +mrt04931IaI T -159 P.10 /16 F -123
<br />SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a)
<br />FLORIDA STATUTES ON PUBLIC ENTITY CRIMES
<br />THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
<br />OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
<br />I . This sworn statement is submitted to e i d j T J � U yo n l4 EJ e.,� jj c &
<br />by aA -y-) e .Nx 1 N c
<br />for C( -4f CD �� — I — C) 1
<br />whose business address is L4 J�LL� Y--) 141a f'v S I C( d I (U
<br />and (if applicable) its Federal Employer Identificarion Number (FEIN) is Z-
<br />(IF the entity had no FEIN, include the Social Security Number of the individual signing this sworn statement:
<br />2. 1 understand that a "public entity crime" as defined in Paragraph 287.I33(1)(g), Florida Statutes, means a violation of
<br />any state or federal law by a person with respect to and directly related to the transaction of business with any public
<br />entity or with an agency or political subdivision of any other state or of the United States, including, but not limited to,
<br />any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any
<br />other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or
<br />material misrepresentation.
<br />3. 1 understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes means a finding
<br />of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial
<br />court of record relating to charges brought by indictment or information after July 1, I989, as a result of a jury verdict,
<br />nonjury trial, or entry of a plea of guilty or polo contenders.
<br />d. I understand that an "affiliate" as defined in Paragraph 287.133(I)(a), Florida Statutes, means:
<br />a. A predecessor or successor of a person convicted of a public entity crime; or
<br />b. An entity under the control of any natural person who is active in the management of the entity and who has been
<br />convicted of a public entity come. The term "affiliate" includes those officers, directors, executives, partners,
<br />shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership
<br />by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income
<br />among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that
<br />one person controls another person. A person who knowingly enters into a joint venture with a person who has
<br />been convicted of a public entity crime in Florida during The preceding 36 months shall be considered an affiliate.
<br />5. 1 understand that a "person" as defined in Paragraph 287.133(l)(e), Florida Statutes, means any nauiral person or entity
<br />organized under The laws of any state or of the United States with the legal power to enter into a binding contract and
<br />which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which
<br />otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers,
<br />directors, executives, partners, shareholders, employees, members, and agents who are active in management of any
<br />entity.
<br />SIGNATURE OF AFFIANT (Printed or Typed Legal Name of Affiant)
<br />State of—, County of / 'J
<br />Swam to and subssjcrib�e%d` before , me this day of i =+ z � , 200 b
<br />y
<br />Notary Seal:
<br />N sty's Xame Printed, Stamped or Typed
<br />EE, ALAN J. PAOLI Personally Known: or Produced Identification COMMISSION # CC 848133 PIRES: September 11, 2003 ded Thru Notary Public Underwriters
<br />Identification Produced
<br />Page 9 of 10
<br />Golden Suand Pktng Lot Fence Bid
<br />of
<br />
|