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<br />
<br />SWORN STATEMENT PURSUANT TO SECTION 287,133(3)(a)
<br />FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
<br />
<br />THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
<br />OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
<br />
<br />1, This sworn statement is submitted to C' (-{ c/ i.~ l-:::-
<br />.---) .
<br />{", v t,y,'(
<br />
<br />~.
<br />SL '\...-/'1
<br />
<br />! !:L l-:;
<br />
<br />gL /:( C'I ;'
<br />
<br />by
<br />
<br />f.. { cy-( D ~
<br />
<br />for {~_7 L- (~., Z C"'.;S;: 1'--, C. ()ESI6.1J ;:; t:: 00, ..../<22::: (2/ L C:; (0 c.,
<br />
<br />whose business address is [' L/ () J I u\ Ie t::- (;e6;!. c: c.F. c.~Jr ;-:::P-/02
<br />
<br />/--'1 (. \ 1'-1 ( c..,At::.e ') 1-- L "3 -:5 ul Lj'
<br />
<br />and (ifapp1icab]e) its Federa] Emp]oyer Identification Number (FEIN) is {; S' - C~<; Z .~ (. L! 2
<br />(IF the entity had no FEIN, include the Socia] Security Number of the individual signing this sworn statement:
<br />
<br />2. 1 understand that a "pub]ic entity crime" as defined in Paragraph 287.133(1)(g), F]orida Statutes, means a violation of
<br />any state or federal law by a person with respect to and directly related to the transaction of business with any public
<br />entity or with an agency or political subdivision of any other state or of the United States, including, but not limited to,
<br />any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any
<br />other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or
<br />material misrepresentation,
<br />
<br />3, ] understand that "convicted" or "conviction" as defined in Paragraph 287, I 33(1)(b), F]orida Statutes means a finding
<br />of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial
<br />court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict,
<br />nonjury tria], or entry of a plea of guilty or nolo contenders,
<br />
<br />4. I understand that an "affiliate" as defined in Paragraph 287.] 33(1)(a), F]orida Statutes, means:
<br />
<br />a, A predecessor or successor of a person convicted of a public entity crime; or
<br />
<br />b. An entity under the control of any natura] person who is active in the management of the entity and who has been
<br />convicted of a public entity come, The term "affiliate" includes those officers, directors, executives, partners,
<br />shareholders, employees, members, and agents who are 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, shall be a prima facie case that
<br />one person controls another person, A person who knowingly enters into a joint vent]Jre with a person who has
<br />been convicted of a public entity crime 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), F]orida Statutes, means any natural person or entity
<br />organized under the laws of any state or of the United States with the legal power to enter into a binding contract and
<br />which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which
<br />otherwise transacts or applies to transact business with a public entity, The term "person" includes those officers,
<br />directors, executives, partners, shareholders, employees, members, and agents who are active in management of any
<br />entity,
<br />
<br />W0~~1 /J .0lJ l~-( /-~LJ 1D~
<br />
<br />SIGNA TURE"OF AFFIANT (Printed or Typed Lega] Name of Affiant)
<br />
<br />Cl' .)
<br />State of { lei I dC:, County of I!} 1(,/' I, " I...//c Ie
<br />Sworn to and subscribed before me this 2'1 1-1\ day of
<br />
<br />.Lui v
<br />
<br />/ Y.J; ! I
<br />
<br />, 2007 by
<br />
<br />
<br />.l
<br />
<br />Personally Known:
<br />
<br />or Produced Identification
<br />
<br />/
<br />
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<br />'I ,C';"''."''"'', d,i. ,~, .,,~, b I'J:llt":,\! ,II, 'I
<br />:' I :.....~:..f;~'..). " .::.~.J~ f.'1 ,.', -'~.r ,. ;=,~, ,- " ; ,- - ,'-" ;-. ,
<br />~ =...,.: ,uia :.:. ~,di t....U,V,MI::.~:I:):'.l [It 00 dEr[861 r
<br />;: :;!~;::~?~;~;::,{i/ EXPiRES, [;~;':;~:;:':\::Jsr' ;~71 20C3 Ir
<br />,11'1,..,.0." Bond'd Til'<'I "''"! ': )...el1,'..,,,....,. I.
<br />:;~~~~i~..~~~~~~.~.~~.~~~;~~~~~;.~~;;~~~~::Ctr~.
<br />
<br />Identification Produced
<br />
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<br />
<br />Page 8 of9
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<br />RFQ Eng Srvcs For Gov InfraSl11iClllre 042407.Doc
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