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<br />11.5.
<br />
<br />11.6.
<br />
<br />[Z]
<br />
<br />D
<br />
<br />1]
<br />
<br />market value under an arm's length agreement, shall be a prime facie case that one person
<br />controls another person. A person who knowingly enters into a joint venture with a person who
<br />has been convicted of a public entity crime in Florida during the preceding 36 months shall be
<br />considered an affiliate.
<br />
<br />I understand that a "person" as defined in Para. 287.133(1 )(e), Florida Statutes, means any natural
<br />person or entity organized under the laws of any state or of the United States with the legal power to
<br />enter into a binding Contract and which Bids or applies to Bid on Contracts for the provision of goods or
<br />services let by a public entity, or which otherwise transacts or applies to transact business with a public
<br />entity. The term "persons" includes those officers, directors, executives, partners, shareholders,
<br />employees, members, and agents who are active in management of any entity.
<br />
<br />Based on information and belief, the statement which I have marked below is true in relation to the entity
<br />submitting this sworn statement. (Indicate which statement applies.)
<br />
<br />Neither the entity submitting this sworn statement, nor any of it's officers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in the management of the entity, nor any
<br />affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1,
<br />1989.
<br />
<br />The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in the management of the entity, or an
<br />affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1,
<br />1989.
<br />
<br />The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in the management of the entity, or an
<br />affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1,
<br />1989, However, there has been a subsequent proceeding before a Hearing Officer of the State of
<br />Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer of the
<br />State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer
<br />determined that it was not in the public interest to place the entity submitting this sworn statement on the
<br />convicted vendor list. (Attach a copy of the final order.)
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE
<br />PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 11,1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND,
<br />THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I
<br />ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO
<br />A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA
<br />STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.
<br />
<br />By /j;/~ ~
<br />
<br />(Sigr:latGre) ~
<br />
<br />Sworn)p and subscribed before me this
<br />hre-+ ~ ri +- 1< I\UN\.
<br />~ I
<br />
<br />(AFFI~~'f.1t~M.~A
<br />
<br />~_ J ~o~mission # DD876615
<br />............. Expires: JULY 07, 2013
<br />BONUED TIiRU ATL.\NTIC BONDING CO.,INe.
<br />
<br />BreI T. BriUenum
<br />
<br />(Printed Name)
<br />Vice President & General Manager
<br />
<br />(Title)
<br />
<br />day of A-j o.ur _,
<br />
<br />~-J/ /
<br />/J~/'
<br />
<br />
<br />Sign9tury?" . otary Public -'state of Florida
<br />/'..,./ -.:--Te C./~ f\-( 0 L I,,~
<br />print or Type Commissioned Name
<br />
<br />20
<br />
<br />
<br />v'
<br />
<br />Personally Known
<br />
<br />OR Produced Identification
<br />
<br />10/1998
<br />
<br />Type of Identification Produced
<br />
<br />3 of 7
<br />
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