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F�' SWORN STATEMENT I TES ON PUBLIC ENTITY Cs�S3)(a), THIS FORM MUST BE SIGNED AND SWORN ER IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO a 1, This sworn statement is submitted to [print name of the public entity] by 7-17;11711 l [print individual's name and title] for 0�.,c' [print name of entity submitting,, sworn s atement] whose business address is and (if applicable) its Federal Employer Identification Number (FEIN) is (If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement: 2, 1 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 ith an person eny with respect l subdi and of any other state the of the United business with any public entity o g States, including, but not limited cal subdivision of any other. goods or of the United States andainvolving entity or an agency or posit antitrust, fraud, theft, bribery, collusion, racketeering, conspracy, or material misrepresentation. ( ) ( ) Florida Sta 3, 1 understand that "con icted" or iction of a public entity erimePwitl�or without an adjudication of guilt, ein or a means a finding of guilt any federal or state trial court of record verdict, non jury trial, entgry of a pgea of gutty or nolo coif detren after July 1, 1989, as a result of a Jury , J 4, 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 licaen natucalnperson who is active affihate e includes hosef officers Tyd and directors, has been convicted of a pub h' executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. Thin equipment or income person among persons whentnott for fair market t value su der an arm's length a pooling of eq p agreement, shall be a prima th a person who has been convicted of a public entity person ime n Flor da during enters into a joint venture p the preceding 36 months shall be considered an affiliate. 5. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural e legal power to person or entity organs and which bids or applies otbidron of the United contracts for the provision sion of goods or services into a binding contract let by a public entity, or which otherwise transacts or applies to transact busi ess sit a public numb. The term "person" includes those officers, directors, executives, partners, and agents who are active in management of an entity. I 00402 -1 03- 4138.A -R Form PUR 7068 (Rev. 06/11/92)