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<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 information 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 />..L 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 of 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 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. However, there has
<br />been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings
<br />and the Final Order 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 place the entity
<br />submitting this swom statement on the convicted vendor list. (Attach a copy of the final order.)
<br />
<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 FILED. 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 INFORMATION CONTAINED IN THIS FORM.
<br />By:
<br />
<br />~~~
<br />
<br />(Signature)
<br />Edd Satterfield
<br />
<br />J
<br />
<br />(Printed Name)
<br />Assistant Vice President
<br />
<br />(Title)
<br />
<br />Sworn to and subscribed before me this 5?" day of ~ 8:'- A. ~-\- , 20~, by
<br />~~~ ~~~~'C'~\~~ .
<br />
<br />4h~V~":Ytf~M 9\.. ~
<br />(~~~NUT~IV~~;~PHERE) _~.r-..~ C v ~
<br />~ ~ ,-- "....n .,~
<br />~.... u- .,
<br />"h~ ~
<br />i ~ ~csr ARt, \
<br />i ci = ~ \ '-. '(\ "'- L:\' tiY\. ~-..S'
<br />~ Q PU 8\. ,c, s E Print or Type Commissioned Name
<br />..~ 'IIIIiO~
<br />\~Iy ~ OR Produced Identification
<br />f'~t!~ rocluced
<br />fl',.....
<br />END OF SECTION
<br />
<br />Signature: Notary Public - State of Florida
<br />
<br />60
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