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<br />SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a) <br />FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES <br /> <br />THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY <br />PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS. <br /> <br />1. <br /> <br />This sworn stalemeI!t, is submitted-.- I <br />to C;, + 1 ot S<.( n n y ~ {J "Belt ('/ hi1=-( <br />by BY"t1q i\{~1 t~v- <br />for~ldzL!( <br />whose business address is ''1 ~ A ,., 1- <"II ~ ,/') .. <br />J aD N6 J,1f1" S7Y~( 0""]::tr, <br /> <br />boo <br />i <br /> <br />N,arnj I PI <br />, <br /> <br />:':?...1/?J 7 <br /> <br />and (if applicable) its Federal Employer Identification Number (FEIN) <br />).0- :1&t t1S'f <br />(If the entity had no FEIN, include the Social Security Number of the individual signing this <br />sworn statement: <br /> <br />2. I understand that a "public entity crime" as defined in Paragraph 287. 133(l)(g), Florida <br />Statutes, means a violation of any state or federal law by a person with respect to and directly <br />related to the transaction of business with any public entity or with an agency or political <br />subdivision of any other state or of the United States, including, but not limited to, any bid or <br />contract for goods or services to be provided to any public entity or an agency or political <br />subdivision of any other state or of the United States and involving antitrust, fraud, theft, <br />bribery, collusion, racketeering, conspiracy, or material misrepresentation, <br /> <br />3, I understand that "convicted" or "conviction" as defined in Paragraph 287.133(l)(b), Florida <br />Statutes means a fmding of guilt or a conviction of a public entity crime, with or without an <br />adjudication of guilt, in any federal or state trial court of record relating to charges brought by <br />indictment or information after July 1, 1989, as a result of a jury verdict, nonjury trial, or entry <br />of a plea of guilty or nolo contenders. <br /> <br />4. I understand that an "affiliate" as defined in Paragraph 287.133(l)(a), Florida Statutes, means: <br /> <br />a, A predecessor or successor of a person convicted of a public entity crime; or <br /> <br />b, An entity under the control of any natural person who is active in the management of the <br />entity and who has been convicted of a public entity come, The term "affiliate" includes <br />those officers, directors, executives, partners, shareholders, employees, members, and <br />agents who are active in the management of an affiliate. The ownership by one person of <br />shares constituting a controlling interest in another person, or a pooling of equipment or <br />income among persons when not for fair market value under an arm's length agreement, <br />shall be a prima facie case that one person controls another person. A person who <br />knowingly enters into a joint venture with a person who has been convicted of a public <br />entity crime in Florida during the preceding 36 months shall be considered an affiliate. <br /> <br />16 <br />