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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 />L Neither the entity submitting this swam 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 Rnal 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 CONTRACTING OFFICER FOR THE
<br />PUBUC ENlTIY 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 SECTION
<br />287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFORMATION
<br />CONTAINED IN THIS FORM.
<br />
<br />By: 1>JGJ<~ (}k,~\ 0 ~\\\\I\~~
<br />(Signature) L NIL )
<br />'~-O.N'r ~~(<:)
<br />(Prin~ed Name)1 \,
<br />~ r \)-f' \ S'1! () Nrt'
<br />(Title)
<br />
<br />Swom to and subscribed before me this I., ft.e.y of ~ ~ by
<br />
<br />(AFFIX NOTARY STAMP HERE) /
<br />~1IJ1fI"1II1I""111111 . .
<br />! ANDREW"OG""''''''''''''''''H'''IIf~ Signature: Nobt,rv P~bllc - State of FlondClj
<br />~ Notary Public S H'NA~ i -A-7VbL~ OG, I-htU~
<br />i My Comm. EX:~/~8f/F2'orJda ,= Print or Type Commissioned Name
<br />c;::~ - com' 011
<br />5""H""'''""""IJ.l:~l:~~~ DD73~_ . i
<br />person~~Jn wn UK""I'5~ ..,tification
<br />Type-ofIaentification Produced
<br />
<br />END OF SECTION
<br />
<br />PAGe 59 OF 78
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