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<br />...,
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<br />..,
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<br />and agen s who are active in management of an entity.
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<br />6.
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<br />Based on information and belief, the statement which I have marked below is true in
<br />relati . n to the entity submitting this sworn statement. [Indicate which statement applies]
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<br />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, nor any affiliate of the entity has been charged with and
<br />convicted of a public entity crime subsequent to July 1, 1989.
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<br />..,
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<br />..,
<br />.
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<br />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, nor any affiliate of the entity has been charged with and
<br />convicted of a public entity crime subsequent to July 1, 1989.
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<br />...,
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<br />
<br />..,
<br />.
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<br />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, nor any affiliate of the entity has been charged with and
<br />convicted of a public entity crime subsequent to July 1, 1989. However, there has been a
<br />subsequent proceeding before a Hearing Officer of the State of Florida, Division of
<br />Administrative Hearings and the Final Order entered by the Hearing Officer of the State of
<br />Florida, Division of Administrative Hearings and the Final Order entered by the Hearing
<br />Officer determined that it was not in the public interest to place the entity submitting this
<br />sworn statement on the convicted vendor list. [attach a copy of the final order]
<br />
<br />,..,
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<br />.
<br />
<br />~
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<br />.
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<br />,..,
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<br />I UNDERSTAND _THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR
<br />THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY
<br />ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN
<br />WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC
<br />ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT
<br />PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANGE
<br />IN THE INFORMATION CONTAINED IN THIS FORM.
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<br />.,
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<br />Sworn to and subscribed before me this
<br />
<br />c:to
<br />
<br />day of
<br />
<br />
<br />, 20J!j.
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<br />i1
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<br />
<br />r1
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<br />.
<br />
<br />....,
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<br />Personally known
<br />OR Produced identification
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<br />.....--
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<br />7=-f.
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<br />-,
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<br />
<br />(Type of identification)
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<br />Form PUR 7068 (Rev. 06/11/92)
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<br />09/09
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<br />00402-2
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<br />03-4122.F
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<br />fO
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