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. . . SWOItN m'ATEMBNT PURSUANT TO SECI10N 21'7.13](3)(.) PLOIUDA STAnrg8. ON PUBUC BNTITV CRIMES lHJS FORM MUST BE. SIONIID AND SWORN TO IN TIlE PRBSENCE Of A NOTARY PUBUC OR OTHER OFfICIAL AUTHORJ'lJID TO ADMINISTER OAnIS. I. Tbia swurt! alaftlmcnl is lubmllUld to 2he City of Sunny Isles Beach by ~~berg Gan1neJ Dos!pn ror RFQ No, 07~3-01 Professional General Engi~i!!p Consulh!lt wl10le bualntu ~ ill 5190 NW 167th Street, Suite 111, Miaml, Fl ~Q14 and (it applicable) Ib Pedenl Employer ldenlificulon Number (PHIN) II G S - 0[...110(, ?:> 7 (IF IIle enlily fwd no PBIN. illCludc die Social Security Number or Ihe individulll aiping lldll sworn st.l2meol: 2. I l.In.da'sflIId 11111 a "public entity Q'ime" lIS dcfilDl it\ Pancraph 287 .1330)(g). Florida SlIItutea. meanl B violation of IIJ1Y .tall: or fatcr.l law by . person willi respecl CO and ditectly rela11ld In the 1t/llJlaction of bUlUali with my public entity Of wi1I1u. aaern:y or politicallubdiviaion or lIIl)' odJcr It.- or of Ibo Unlled Slalll:l. includlns. but not lfmlted 10. any bi.d or oonlnct for aooos or lCtVices 10 be provided 10 any public entity or an a~ or political But."i;viaioo of any ot1Ier ltale or of Ihe UnilDd SIaIieI arid involvtna IntIIrUllt, fnIud, theft, bribery. colluaion. racke~. evo;p1rucy. or material __pneenhltlon, ], .l ondersland that ''oonvicfDd'' 0( ''convictlon'' III dafU\Od in l'araer'Jlll287.J33(l)(b), Elmi!!! ~ meIJl\I a finding of auill or . L'OIlviction of II public entity crime, with or without In Ilijudk:alion of gullt. in any federal or slale trilll court ofRlCOrd ",lltins to charJ!II brousbl by indletmeDt Of infornMltion ~ Jllly I. 1989.151 reault of. jul'J YWCIIct. ootUury trial. or entty of. plea of pilly OJ' nolo <:O**', 4, I uadIlnlaDd tb.Ilb ".mlia" u defiaed ill v.....eph J81.131(I)(a). Florida 8ra...., meaDS: I. A ~r or lUOOllUOI' of. panon convicted of a p.IIIlk: entity ahm: or b. An entity under the control of In)' naturaJ petIOli wbo is active in tbc D1IIlI~mlllIt Dr the entity and wbo has been convict8d of . pubHc entity 00". The terllJ "affiliatt" inclllllel tbDse otflcets. dil'Ktorl, ellec:utiwa, partners. shareholders. ~lo,eea. J1Emben. mll(!lenb who are ~vc in ~ 1'lIII18~t of an llffiliate. Tht ownerehtp by ODC penoo of Ihuea DOJlIiIl1lUting I IOUoIrollinl inttRSt in aootbtJr perlOIl, or I pooling of equipment or income a11lOt1J peI1On5 when not for fair mukd V111\Jll1Rldef 10 .ut', 1enIIh Igreement, Iha" be D prima fw:ie cue Ibat OOC perIOn amll'Ola aoodta: penon. ^ penon wfIo kMwlna1y enlzra iulo a joint \It'll\tun: with. person who has been convicald of I public entity cdme in Florida during Ihe precedllll 36 MOIltl\s shoJI be considc:rcd an Itfi.liale, 5. J UDdmtaod Ulal1 .'pcnon" u deftned in Paragraph 287, I 33fIXe), Florida Statum. mMnli any nabnl penou or entity orpnl7.ed u..- tile laWl; of IUIY ._ or or the United Stalel with the Icpl powa' to mIet' Into a btndbts conlnel and which bicla or aPl'I.. Iu bid on otJNrad6 for tile provi.lon or aoOOs or se(vm lee by . p\lblic emily. or which othanriae ~ or appUca In crar..d hualneal wilh a public earilY, The term "person" includes !bOle Oft"lCeU. djreclOrs. eJl.OCUIlveI. pertne~. aharebolden. cmplo)'tlN. membeR. and aaenLS who are aClive in manapmenl of any ~~LL --, _~ c..F\R.D[',le-~ ~ OF AFFIANT (Prinled 01' Tytxd LepI NUJIIl 0" Aft1AJ1t) Stalil:of F da ~of~D~'OE..- Sworn to ADd flubKribed before metilb~ day or N t<Ll L . ~1 by ~~Iq~::u~~ N~~I, PertonaJly Koown: ~ ~ Produced Idenliflcaoon _ldeo.llfbLion Produced _ ~ JBAJIl REBHOLZ .e. ~'t' COMMISSION" OD44',.-J 1.; ~ eXPIRES: Oel- =_ If _10'" 1'lOlIM- \tOlI-- Page S of9 RFQ 01..a3-Q1 Engineering Srvs Bridge Rev/aed (Addendum. I)