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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
<br />OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATH.
<br />1 . This sworn statement is submitted to Sunnv Isles Beach
<br />by C. Michael Kelsey
<br />for .lade Co muni ati n a Inc
<br />whosebusmess address is 6610 E. Roizers Circle
<br />Boca Raton, F1. 33487
<br />and (if applicable) its Federal Employer Identification Number (FEIN) is _65- 0002108 -_
<br />(IF the entity had no FEIN, include the Social Security Number of the individual signing this swom statement:
<br />2. 1 understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a
<br />' violation of any state or federal law by a person with respect to and directly related to the transaction of
<br />business with any public entity or with an agency or political subdivision of any other state or of the United
<br />States, including, but not limited to, any bid or contract for goods or services to be provided to any public
<br />entity or an agency or political subdivision of any other state or of the United States and involving antitrust,
<br />fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.
<br />3. 1 understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes means a
<br />' finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal
<br />or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a
<br />result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contenders.
<br />' 4. I understand that an "affiliate" as defined in Paragraph 287.133(1)(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
<br />' has been convicted of a public entity come. The term "affiliate" includes those officers, directors,
<br />executives, partners, shareholders, employees, members, and agents who are active in the management of
<br />an affiliate. The ownership by one person of shares constituting a controlling interest in another person,
<br />or a pooling of equipment or income among persons when not for fair market value under an arm's
<br />t length agreement, shall be a prima facie case that one person controls another person. A person who
<br />knowingly enters into a joint venture with a person who has been convicted of a public entity crime in
<br />Florida during the preceding 36 months shall be considered an affiliate.
<br />' 5. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural person
<br />or entity organized under the laws of any state or of the United States with the legal power to enter into a
<br />binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a
<br />' public entity, or which otherwise transacts or applies to transact business with a public entity. The term
<br />"person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents
<br />who are active in management of any entity.
<br />1
<br />April 39th, 2004
<br />Signature Date
<br />' Sworn to and subscribed before me this 30th day of April 2004, by
<br />C. Michael Kelsey who is personally known to me or has pro -Vided
<br />' known
<br />as identification.
<br />Notary Seal:
<br />' Notary Signature
<br />,ir % NICOLE VAUDFVN
<br />iP
<br />MY COMMISSION # DD 260948
<br />�•. EXPIRES: November 28, 2007
<br />" ftl BonNtl Thru Notary Pibk Underwriters
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