|
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />..
<br />I.
<br />I
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />.
<br />..
<br />I.
<br />i.
<br />I.
<br />.
<br />,.
<br />.
<br />I.
<br />.
<br />.
<br />.
<br />,.
<br />
<br />6. Based on information and belief, the statement which I have marked below is true in a relation to
<br />the entity submitting this sworn statement. (Please indicate which one (1) of the following three
<br />(3) statements is applicable.)
<br />
<br />XX_ (1) Neither the entity submitting this sworn statement, nor any of its officers, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active in the management
<br />of the entity, or any affiliate of the entity has been charged with and convicted of a public entity
<br />crime within the past 36 months,
<br />
<br />_(2) The entity submitting this sworn statement, or one or more of its officers, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active in the management
<br />of the entity, or any affiliate of the entity has been charged with and convicted of a public entity
<br />crime within the past 36 months,
<br />
<br />_(3) The entity submitting this sworn statement, or one or more of its officers, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active in the management
<br />of the entity, or agents who are active in management of the entity, or any affiliate of the entity has
<br />been charged with and convicted of a public entity crime within the past 36 months. However, there
<br />has been a subsequent proceeding before a Hearing Officers of the State of Florida, Division of
<br />Administrative Hearings and the Final Order by the Hearing Officer determined that it was not in the
<br />public interest to place the entity submitting this sworn statement on the convicted vendor list.
<br />(Attached is a copy of the final order.)
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING
<br />OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR
<br />THE PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31
<br />OF THE CALENDAR YEAR IN WHICH IT IS FILED AND FOR THE PERIOD OF THE
<br />CONTRACT ENTERED INTO, WHICHEVER PERIOD IS LONGER. I ALSO UNDERSTAND
<br />THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A
<br />CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017,
<br />FLORI A STATUTES, FOR THE CATEGORY TWO OF ANY CHANGE IN THE
<br />INE TION CO I D IN THIS FORM.
<br />
<br />
<br />Antonio G. Acosta, P.E.
<br />(Printed or Typed Legal Name of Affiant)
<br />
<br />State of Florida County of Miami-Dade +11 A I
<br />Sworn to and subscribed before me this 20 day of 11.3 u s-r
<br />
<br />, 2007 by
<br />
<br />A nt 0 n i 0 A C 0 ~ f Ct
<br />~IU\~I~~ C.S,VCU(L- Esi-mdQ
<br />Notary's Nam Pnnted, Stamped or Typed
<br />
<br />Notary Seal:
<br />
<br />,,~~'Jj:tr YUNEISY C. SUAREZ.ESTRADA
<br />!.'#!'. .,.% MYCOMMISSION#DD638195
<br />: . :~I EXPIRES: March 16, 2011
<br />,,~ Bonded Thru Notary Public Underwriters
<br />
<br />Personally Known:
<br />
<br />><
<br />
<br />
<br />or Produced Identification
<br />
<br />Identification Produced
<br />
|