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<br />SWORN STATEMENT PURSUANT TO SECfION 287.13J(3)(R)
<br />FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
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<br />THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
<br />OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
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<br />I. This swom statement is submitted to L ,.,.,/ 0 r: So/NII!)/.75 it: > 8 c /let.:}
<br />by r./!lrJ)( fl. 1'/(1 <I rc-f'/f'jC 11 '0
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<br />for T (i fl /lit c') ~
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<br />whose business address is
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<br />and (if applicable) its Federal Employer Identification Number (FEIN) is
<br />(Ir the entit), had no FEIN, include the Social Securit)' Number of tbe individual signing tbis sworn statement:
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<br />2. I understand that a "public entity crime" as defined in Paragraph 287,133(1)(g), Florida Statutes. means a violation of
<br />any state or federnllaw by a person with respect to "nd directly related to the transaction of business with 1111)' public
<br />entity or with an agcnc)' or political subdivision ofnny other state or of the United States, including, but not limited to,
<br />on)' bid or contract for goods or services 10 be provided to any public entit)' or an agenc)' or political subdivision of an)'
<br />other state or of the United States and involving ontilTust, fraud, theft, hribery, collusion, racketeering, conspirac)', or
<br />material misrepresentation.
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<br />3. I understand that "convicted" or "conviction" as defined in ('aragraph 287.133(1)(b), .Elm.iilll ~ means a finding
<br />of guilt or a conviction of n public entity crime, wilh or without an adjudication of guill, in any federal or state lrial
<br />court of record re!nting to charges brought by indictment or information aftcr Jul)' I, 1989, os Q.result ofa jur)' verdict,
<br />nonjury trial, or enlr)' oC a plea of guilty or nolo contenders.
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<br />4, I understand that an "nfliliatc" as defined in Paragraph 287.1 33(1)(a), Florida Statutes. meons:
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<br />Q, A predecessor or successor ofa person convicted oCa public entity crime; or
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<br />b, An entity under thc control of alty natural person who is active in the management ofthe entity and who has been
<br />cOnl'icted of a public entity come, The teml "affiliate" includes those officers, directors, execlllives, partners,
<br />shareholders, emplo)'ees, members, and agents who arc 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, shull be Q prima Cucie case that
<br />one person controls another person, A person who knowingly enters into a joint venture with a person who has
<br />been convicled oC a pub! ic enlil)' crime ill Florida during the prect:ding 36 months shall be ctmsidered an afminle.
<br />5, I understand that a "person" us defined in Paragraph 287.133(1)(e), Florida Statutes, means an)' natural person or entit)'
<br />organized under the lall's of an}' stale or of the United States Wilh the legal power to cnler into It binding contract and
<br />which bids 01' applies to bid on contracts for the provision of goods 01' services let by a public entity, or which
<br />olherwise lrnnsacts or applies 10 transact business with a public entity, The term ''persoll'' includes those officers,
<br />directors, executives, partners, shareholders, employees, members, and ogems who arc active in management of an)'
<br />entity. oJ L
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<br />~.:< fl. ,/lr{' /iVlf'~'~ .,!-Itc,x /1 HJ.\/~' ~i .,./ID
<br />SIGNATURE OF AFFIANT / (Printed or TJped Legal Name of Amant)
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<br />State of rlr:i!I'l>/} Count)' of i3,eo/.J.;I1,t!/)
<br />Sworn..o and subsc i ed before me this -2~_ day of
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<br />Jilt{ C( /,~ L 1If/t',d,/
<br />Notary's Name Printed, Stamped orT}'ped
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<br />Personall}' Known: .,/'" or Produced Identification Idcntification Produced
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<br />Notm)' Senl:
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<br />.:~~~~',;~;;..,.. NATALIE CHACIN
<br />~1 Notaly Public. State 01 Florida
<br />\i~fMy C<lmmiSsion Expiras Jul24, 2010
<br />.,;'f..rr,,~.,,'~ ColTllllis3lon # DO 577274
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<br />RFQ 07-03-01 Engineering Srvs Bridge Revised (AddendulIl I ).doc
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