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<br />person who has been convicted of a public entity crime in Florida during the
<br />preceding 36 months shall be considered an affiliate.
<br />
<br />5. I understand that a "person" as defined in Paragraph 287.133(l)(e), Florida Statutes,
<br />means any natural person or entity organized under the laws of any state or of the United
<br />States with the legal power to enter into a binding contract and which bids or applies to
<br />bid on contracts for the provision of goods or services let by a public entity, or which
<br />otherwise transacts or applies to transact business with a public entity, The tenn
<br />"person" includes those officers, directors, executives, partners, shareholders, employees,
<br />members, and agents who are active in management of any entity.
<br />
<br />6. Based on infonnation 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
<br />tl;Yfollowing three (3) statements is applicable.)
<br />
<br />~ (1) Neither the entity submitting this sworn statement, nor any of its officers,
<br />directors, executives, partners, shareholders, employees, members, or agents who are active
<br />in the management of the entity, or any affiliate of the entity has been charged with and
<br />convicted of a public entity crime within the past 36 months,
<br />
<br />_(2) The entity submitting this sworn statement, or one or more of its officers,
<br />directors, executives, partners, shareholders, employees, members, or agents who are active
<br />in the management of the entity, or any affiliate of the entity has been charged with and
<br />convicted of a public entity crime within the past 36 months.
<br />
<br />_(3) The entity submitting this sworn statement, or one or more of its officers,
<br />directors, executives, partners, shareholders, employees, members, or agents who are active
<br />in the management of the entity, or agents who are active in management of the entity, or
<br />any affiliate of the entity has been charged with and convicted of a public entity crime
<br />within the past 36 months. However, there has been a subsequent proceeding before a
<br />Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final
<br />Order by the Hearing Officer determined that it was not in the public interest to place the
<br />entity submitting this sworn statement on the convicted vendor list. (Attached is a copy of
<br />the final order.)
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE
<br />CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN
<br />PARAGRAPH 1 (ONE) ABOVE IS FOR THE PUBLIC ENTITY ONLY AND, THAT
<br />THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN
<br />WHICH IT IS FILED AND FOR THE PERIOD OF THE CONTRACT ENTERED INTO,
<br />WHICHEVER PERIOD IS LONGER. I ALSO UNDERSTAND THAT I AM REQUIRED
<br />TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN
<br />EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287,017,
<br />FLORIDA STATUTES FOR THE CATEGORY TWO OF ANY CHANGE IN THE
<br />INFORMATIO CONTAINED IN THIS FORM,
<br />
<br />
<br />Hector M. Ortiz, President
<br />(Printed or Typed Legal Name of Affiant)
<br />
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<br />SIGNATURE OF AFFIANT
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