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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 OATHS.
<br />1 . This sworn statement is submitted to 0, 1 TV �, 1.1 V1 n`� t
<br />by 5%i E P--'
<br />-
<br />for 0-A.-EA N' l /J G� T CYi\ -�
<br />whose business address is
<br />and (if applicable) its Federal Employer Identification Number (FEIN) isj.76 14 -7-YI3
<br />(IF the entity had no FEIN, include the Social Security Number of the individual signing this sworn
<br />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. 1 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
<br />and who has been convicted of a public entity come. The term "affiliate" includes those officers,
<br />directors, executives, partners, shareholders, employees, members, and agents who are active in the
<br />management of an affiliate. The ownership by one person of shares constituting a controlling interest in
<br />another person, or a pooling of equipment or income among persons when not for fair market value under
<br />an arm's length agreement, shall be a prima facie case that one person controls another person. A person
<br />who knowingly enters into a joint venture with a person who has been convicted of a public entity crime
<br />in 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
<br />natural person or entity organized under the laws of any state or of the United States with the legal power
<br />to enter into a bind' g contract and which bids or applies to bid on contracts for the provision of goods or
<br />services let by a u lic entity, or which otherwise transacts or applies to transact business with a public
<br />entity. The to m; "person" includes those officers, directors, executives, partners, shareholders,
<br />employees, me ers, and agents who are active in management of any entity.
<br />Signature ate
<br />Sworn to and subscribed before me this day of � 2004, by
<br />�S - r /5��ff Ek who is personally known to me or has provided
<br />• as identification.
<br />Notary Seal: Y. Tina G Kwiatkowski
<br />My Commission DD178W8 Notary Sign , tr
<br />a J Expires January 24, 2007
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