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<br />5, I understand that a "person" as defined in Paragraph 287.133(l)(e), Florida Statutes, means any
<br />natural person or entity organized under the laws of any state or of the United States with the
<br />legal power to enter into a binding contract and which bids or applies to bid on contracts for
<br />the provision of goods or services let by a public entity, or which otherwise transacts or applies
<br />to transact business with a public entity. The term "person" includes those officers, directors,
<br />executives, partners, shareholders, employees, members, and agents who are active in
<br />management of any entity.
<br />
<br />6, Based on information and belief, the statement which I have marked below is true in a
<br />relation to the entity submitting this sworn statement. (please indicate which one (1) of the
<br />tpllowing three (3) statements is applicable,)
<br />
<br />~ (1) Neither the entity submitting this sworn statement, nor any of its officers, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active in the
<br />management of the entity, or any affiliate of the entity has been charged with and convicted of a
<br />public entity crime within the past 36 months,
<br />
<br />(2) The entity submitting this sworn statement, or one or more of its officers, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active in the
<br />management of the entity, or any affiliate of the entity has been charged with and convicted of a
<br />public entity crime within the past 36 months.
<br />
<br />(3) The entity submitting this sworn statement, or one or more of its officers, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active in the
<br />management of the entity, or agents who are active in management of the entity, or any affiliate
<br />of the entity has been charged with and convicted of a public entity crime within the past 36
<br />months. However, there has been a subsequent proceeding before a Hearing Officers of the State
<br />of Florida, Division of Administrative Hearings and the Final Order by the Hearing Officer
<br />determined that it was not in the public interest to place the entity submitting this sworn
<br />statement on the convicted vendor list. (Attached is a copy of the final order.)
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING
<br />OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS
<br />FOR THE PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH
<br />DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS Fll..ED AND FOR THE
<br />PERIOD OF THE CONTRACT ENTERED INTO , WHICHEVER PERIOD IS LONGER. I
<br />ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY
<br />PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOlD AMOUNT
<br />PROVIDE ECTION 287,017, RIDA STATUTES FOR THE CATEGORY TWO OF
<br />ANY C INFOR TION CONTAINED IN THIS FORM.
<br />
<br />rxaGl w ft--r:fJ
<br />
<br />(Printed or Typed Legal Name of Mfiant)
<br />
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<br />17
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