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<br />----
<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 />11.5. 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 />11.6. 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 swom 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 swam statement, or one or more of its officers, directors, ex~utives, 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 swom 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 UNT PROVIDED IN SECTION 287.017, FLORIDA
<br />STATUTES, FOR CATEGORY TWO OF ANY, CHAN HE INFORMATION CONTAINED IN THIS FORM.
<br />
<br />By:
<br />
<br />
<br />(Signature) \ \J '1
<br />(Printed Name)
<br />~'f
<br />(Title)
<br />
<br />Sworn to and subscribed before me ~his L day of J u I '1
<br />\ '01 ~D/N .
<br />
<br />(AFFIX NOTARY STAMP HERE)
<br />
<br />~.p,. ~ I J'.J
<br />/V\...SLr't"~
<br />
<br />,.~~~~~ KRYSTAl COURCHENE
<br />;.!'J:i.'>;~*?: MY COMMISSION # EE 000266
<br />~&:~,.~ ;,oo~ EXPIRES: October 12, 2014
<br />~.Oi ;~.~. ded Thm No"n' Pubic Umlerwriters
<br />'''It'' W>1
<br />
<br />Signature: Notary Public -
<br />
<br />
<br />I (
<br />, 20_, by
<br />
<br />Print or Type Commissioned Name
<br />
<br />Personally Known
<br />
<br />OR Produced Identification
<br />
<br />Type of Identification Produced
<br />
<br />10/1998
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