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<br />c
<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 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 />/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 Oreler entered by the Hearing Officer of the State of Florida, 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 />
<br />o
<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 />JAAA ~f-
<br />mAfsen~~~Af-{;('ct
<br />C1, r-lPrinted Name) k-.. C"c.. r
<br />_1)\ e:t 7Y'P r At\c'0) l.JtIl ce
<br />(Titld)
<br />Q...?-h ~ .
<br />Sworn to and subscribed before me thisV - day of A ~ -0 ,20 OS, by
<br />~n'=::.- S...(--D-~~ .
<br />
<br />(AFFIX:NOT~RY STAMP HERE) 'i ~ +tt A A'l--f
<br />. ' ERIKA HUNT t ~ ~
<br />NOTARY PUBLICi AlABAMA STATE AT lARGE Signature: Notary Public - State of ROAde- ~~ ~
<br />MY COMMISSION EXPIRES 03-29-2010 Fv ~ Ie 0-- t-h A n-r
<br />\W "".:..! C Print or Type Commissioned Name
<br />
<br />Personally Known . / OR Produced Identification
<br />Type of Identification Produced
<br />
<br />o
<br />
<br />END OF SECTION
<br />
<br />60
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