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<br />PUBLIC ENTITY CRIMES
<br />
<br />City of Sunny Isles Beach
<br />18070 Collins Avenue
<br />Sunny Isles Beach, FL 33160
<br />Telephone: (305) 947-0606 Fax: (305) 949-3113
<br />
<br />SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a)
<br />FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
<br />
<br />PUBLIC ENTITY CRIMES
<br />
<br />Pursuant to the provisions of paragraph (2) (a) of Section 287.133, Florida State Statutes - A person or affiliate
<br />who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a
<br />Bid on a Contract to provide any goods or services to a public entity, may not submit a Bid on a Contract with a
<br />public entity for the construction or repair of a public building or public Work, may not submit Bids on leases of
<br />real property to a public entity, may not be awarded to perform Work as a Contractor, supplier, Sub-Contractor, or
<br />Consultant under a Contract with any public entity, and may not transact business with any public entity in excess
<br />of the threshold amount Category Two of Sec. 287.017, FS for thirty six months from the date of being placed on
<br />the convicted vendor list'
<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 />11.1. This sworn statement is submitted to City of Sunny Isles Beach
<br />by &a~w ~~I/;Y7~ . PrL9;~
<br />nn In IVI ua; name an tl e / .
<br />
<br />for ~n1 n~m': o! e~b~'~ s~om~atemCr uJJ \;1. / ! f)-fl S / h ~ r; JJ V7UL-fJ
<br />
<br />whose business address is: vi. ('
<br />c); \" P?fVJ k /-H/L LtJu/-h / 0
<br />Il)~~ V &-fL!L / IU yl / O~ 0 1
<br />and (if applicable) its Federal Employer Identification number (FEIN) is l1 ~ /9 t.f)'3 () 3.
<br />(If the entity had no FEIN, include the Social Security Number of the individual signing this sworn
<br />statement: .)
<br />
<br />-rH nc>~
<br />
<br />11.2. I understand that a l)ublic entity crim e"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 with the
<br />United States, including, but not limited to, any Bid or Contract for goods or services to be provided to any
<br />public entity or an agency or political subdivision of any other state of the United States and involving
<br />antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.
<br />
<br />11.3. I understand that tonvicted"or tonviction"as defi ned in Para. 287.133(1)(b), Florida Statutes, means a
<br />finding of guilt or a conviction of a public entity crime, with or without an adj,Jdication of guilt, in any
<br />federal or state trail court of record relating to charges brought by indictment or information after Lily 1,
<br />1989, as a result of a j,Jry verdict, non-j,Jry trial, or entry of a plea of guilty or nolo contendere.
<br />
<br />11.4.
<br />
<br />I understand that an ~ffiliate"as defined in Para. 287.133(1)(a), Florida Statutes, means:
<br />
<br />a.) predecessor or successor of a person convicted of a public entity crime; or
<br />
<br />b.) Any 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 crime. The term ~ffiliate"includes those officers,
<br />directors, executors, partners, shareholders, employees, members, and agents who are active in
<br />the management of an affiliate. The ownership by one person of shares constituting a controlling
<br />interest in another person, or a pooling of eqi pment or income among persons when not for fair
<br />
<br />DECEMBER 28,2010 2 of 7
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