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<br />executives, partners, shareholders, employees, members, and agents who are active in <br />management of any entity. <br /> <br />11.6. Based on information and belief, the statement which I have marked below is true in relation to <br />the entity submitting this sworn statement. (Indicate which statement applies.) <br /> <br />x <br /> <br />Neither the entity submitting this sworn statement, nor any of it's officers, directors, executives, <br />partners, shareholders, employees, members, or agents who are active in the management of <br />the entity, nor any affiliate of the entity has been charged with and convicted of a public entity <br />crime subsequent to July 1,1989. <br /> <br />The entity submitting this sworn statement, or one or more of its officers, directors, executives, <br />partners, shareholders, employees, members, or agents who are active in the management of <br />the entity, or an affiliate of the entity has been charged with and convicted of a public entity <br />crime subsequent to July 1, 1989. <br /> <br />The entity submitting this sworn statement, or one or more of its officers, directors, executives, <br />partners, shareholders, employees, members, or agents who are active in the management of <br />the entity, or an affiliate of the entity has been charged with and convicted of a public entity <br />crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a <br />Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order <br />entered by the Hearing Officer of the State of Florida, Division of Administrative Hearings and the <br />Final Order entered by the Hearing Officer determined that it was not in the public interest to <br />place the entity submitting this sworn statement on the convicted vendor list. (Attach a copy of <br />the final order.) <br /> <br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRAOlNG OFFICER FOR THE <br />PUBUC ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBUC ENTITY ONLY <br />AND, THAT THIS FORM IS VAUD THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS <br />FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBUC ENTITY PRIOR TO <br />ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SEOlON <br />287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFORMATION <br />CONTAINED IN THIS FORM. <br /> <br />BY:~~ <br />~nature) S /J ct. <br />t')u-~ . f(: ;r tA- <br />(pr~ed. v--' <br />(Title) <br /> <br /> <br /> <br />n subscribed before me this 1/ <br />~ eJAtV <br /> <br />il#l~Pt\. No'try Publle alalll of Flortda <br />. . !:IlIlnll Moaeh!lltf <br />~ c:.. bo. ~ MV COITI",i'lIiof1 00747368 <br />~o,.~ EIIl)lra, 03lO1/201~ <br /> <br />Perso a n <br /> <br />Type of Identificatio <br /> <br /> <br /> <br />ced Identification <br /> <br />END OF SEOlON <br /> <br />PAGE S9 OF 78 <br />