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<br />PUBLIC ENTITY CRIMES
<br />
<br />City of Sunny Isles Beach
<br />1 B070 Collins Avenue
<br />Sunny Isles Beach, FL 33160
<br />Telephone: (305) 947-0606 Fax: (305) 949-3113
<br />
<br />SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a)
<br />FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
<br />
<br />PUBLIC ENTITY CRIMES
<br />
<br />Pursuant to the provisions of paragraph (2) (a) of Section 287,133, Florida State Statutes - j\ person or affiliate
<br />who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a
<br />Bid on a Contract to provide any goods or services to a public entity, may not submit a Bid on a Contract with a
<br />public entity for the construction or repair of a public building or public Work, may not submit Bids on leases of
<br />real property to a public entity, may not be awarded to perform Work as a Contractor, supplier, Sub-Contractor, or
<br />Consultant under a Contract with any public entity, and may not transact business with any public entity in excess
<br />of the threshold amount Category Two of Sec, 287.017, FS for thirty six months from the date of being placed on
<br />the convicted vendor Iise
<br />
<br />THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
<br />OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
<br />
<br />11.1. This sworn statement is submitted to City of Sunny Isles Beach
<br />by ~11f?lrrla,lu I &-1/" Y] ~ , P r L9 ;duJ
<br />tal I M name ana tI e / .
<br />
<br />for ~17~ i~rJil&ilt J [fWJ1 ~LL/~s /t1.k-rtJaA tr?UL-fl
<br />na Of en 5utJ In sworn statemen
<br />
<br />whose business address is: I ri. (' ff
<br />,y/r /'I)/J IL ffVL _au /-t, /!)..,., Ff ()~
<br />
<br />fl)~ YtHL!L / !UV /otJo1
<br />
<br />and (if applicable) its Federal Employer Identification number (FEIN) is /':J -1'1 tfS- '5l:J 3,
<br />(If the entity had no FEIN, include the Social Security Number of the individual signing this sworn
<br />statement: ,)
<br />
<br />11.2. I understand that a ~ublic entitycrim e''as defined in Paragraph 287,133( 1)(g), Florida Statutes, means a
<br />violation of any state or federal law by a person with respect band directly related to the transaction of
<br />business with any public entity or with an agency or political subdivision of any other state or with the
<br />United States, including, but not limited to, any Bid or Contract for goods or services to be provided to any
<br />public entity or an agency or political subdivision of any other state of the United States and involving
<br />antitrust. fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.
<br />
<br />11.3, I understand that tonvicted"or tonviction"as defi ned in Para. 287,133(1)(b), Florida Statutes, means a
<br />finding of guilt or a conviction of a public entity crime, with or without an adjJdication of guilt, in any
<br />federal or state trail court of record relating to charges brought by indicbnent or information after lily 1,
<br />1989, as a result of a jJry verdict, non-pry trial, or entry of a plea of guilty or nolo contendere.
<br />
<br />11.4. I understand that an ~ffiliate"as defined in Para, 287.133(1 )(a), Florida Statutes, means:
<br />
<br />a.)
<br />b.)
<br />
<br />predecessor or successor of a person convicted of a pUblic entity crime; or
<br />
<br />Any entity under the cOntrol of any natural person who is active in the management of the entity
<br />and who has been convicted of a public entity crime, The term laffjliate"includes those officers,
<br />directors, executors, partners, shareholders, employees. members, and agents who are active in
<br />the management of an affiliate, The ownership by one person of shares constituting a controlling
<br />interest in another person, or a pooling of eqi pment or income among persons when not for fair
<br />
<br />2of7
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<br />OECEMBE~ 2B, 2010
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