|
<br />o
<br />
<br />SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a),
<br />FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
<br />THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR
<br />OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS,
<br />C ~~~~f'~~~~~~n~\ cS Beach
<br />
<br />1,
<br />
<br />This sworn statement is submitted to
<br />
<br />IZubcn A\-c:VI
<br />[print individual's name and title\ -J,..
<br />lie 0 n I
<br />[print name of ent; submitting swo n statement]
<br />
<br />by
<br />
<br />for
<br />
<br />
<br />whose business address is
<br />
<br />19f:D
<br />fV\; Ctrn;
<br />
<br />Bi~L/nc Blud ~ 2D4-
<br />,FL- 5~loB
<br />
<br />2.
<br />
<br />and (if applicable) its Federal Employer Identification Number (FEIN) is OlD" 1 ZqOO Ss
<br />
<br />(If the entity has no FEIN, include the Social Security Number of the individual signing this sworn
<br />statement: ,)
<br />
<br />I understand that a "public entity crime" as defined in Paragraph 287.133(1 )(g), Florida Statutes,
<br />means a violation of any state or federal law by a person with respect to and directly related to
<br />the transaction of business with any public entity or with an agency or political subdivision of any
<br />other state or of the United States, including, but not limited to, any bid or contract for goods or
<br />services to be provided to any public entity or an agency or political subdivision of any other
<br />state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering,
<br />conspiracy, or material misrepresentation.
<br />
<br />3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1 )(b), Florida
<br />Statues, means a finding of guilt or a conviction of a public entity crime, with or without an
<br />adjudication of guilt, in any federal or state trial court of record relating to charges brought by
<br />inqictment or information after July 1, 1989, as a result of a jury verdict, nonjury trial, or entry of a
<br />plea of guilty or nolo contendere.
<br />
<br />o
<br />
<br />4. I understand that an "affiliate" as defined in Paragraph 287,133(1 )(a), Florida Statutes, means:
<br />
<br />1. A predecessor or successor of a person convicted of a public entity crime; or
<br />2. An entity under the control of any natural person who is active in the management of the
<br />entity and who has been convicted of a public entity crime. The term "affiliate" includes those
<br />officers, directors, executives, partners, shareholders, employees, members, and agents who
<br />are active in the management of an affiliate, The ownership by one person of shares
<br />constituting a controlling interest in another person, or a pooling of equipment or income among
<br />persons when not for fair market value under an arm's length agreement, shall be a prima facie
<br />case that one person controls another person, A person who knowingly enters into a joint
<br />venture with a person who has been convicted of a public entity crime in Florida during the
<br />preceding 36 months shall be considered an affiliate.
<br />
<br />S, I understand that a "person" as defined in Paragraph 287.133(1)( e), Florida Statutes, means any
<br />natural person or entity organized under the laws of any state or of the United States with the
<br />legal power to enter into a binding contract and which bids or applies to bid on contracts for the
<br />provision of goods or services let by a public entity, or which othelWise transacts or applies to
<br />transact business with a public entity, The term "person" includes those officers, directors,
<br />executives, partners, shareholders, employees, members, and agents who are active in
<br />management of an entity.
<br />
<br />o
<br />
<br />Final Version
<br />
<br />00402-1
<br />
|