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<br />
<br />officers, directors, executives, partners, shareholders, employees, members, and agents who are active in
<br />management of any entity.
<br />
<br />11.6. Based on infonmation and belief, the statement which I have marked below is true in relation to the entity
<br />submitting this sworn statement. (Indicate which statement applies.)
<br />
<br />_ Neither the entity submitting this sworn statement, nor any of it's officers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in the management 01 the entity, nor any affiliate of the
<br />entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989.
<br />
<br />_ The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the
<br />entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989.
<br />
<br />_ The entity submitting this sworn statement, or one or more 01 its officers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the
<br />entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has
<br />been a subsequent proceeding before a Hearing Officer of the State of Rorida, Division 01 Administrative Hearings
<br />and the Final Order entered by the Hearing Officer of the State of Rorida, Division of Administrative Hearings and the
<br />Final Order entered by the Hearing Officer detennined that it was not in the public interest to place the entity
<br />submitting this sworn statement on the convicted vendor list. (Attach a copy of the final order.)
<br />
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<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC
<br />ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS
<br />FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS ALED. I ALSO
<br />UNDERSTAND 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, FLORIDA
<br />STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFO ATION CONTAINED IN THIS FORM.
<br />By:
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<br />
<br />(Signature)
<br />Joe Blanchard
<br />(Printed Name)
<br />Division Director
<br />(Title)
<br />
<br />Sworn to and subscribed before me this if:. day of A LA 0L1'Sr , 20~, by
<br />~ 15 LA .-J( .
<br />LARA ARN LD
<br />
<br />(AFFIX NOTARY STAMP HERE)
<br />
<br />
<br />7059
<br />t..:.' .~1 EXPlRES: February 28, 2009
<br />Slgn~~~~~d~~~h~s
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<br />I
<br />
<br />Print or Type Commissioned Name
<br />
<br />Personally Known OR Produced Identification
<br />Type of Identification Produced
<br />
<br />END OF SECTION
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<br />60
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