|
<br />')
<br />')
<br />)
<br />,)
<br />)
<br />')
<br />)
<br />)
<br />-)
<br />)
<br />)
<br />)
<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.
<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 />11.6.
<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 />~
<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 />, )
<br />
<br />)
<br />~ )
<br />},
<br />, )
<br />)
<br />)
<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 />f )
<br />)
<br />)
<br />)
<br />)
<br />}
<br />)
<br />)
<br />~
<br />}
<br />)
<br />)
<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 TW02Y' CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.
<br />
<br />By. .~~
<br />
<br />( ign ture)
<br />tluic.l Wi.i,Sscf
<br />(PrinJ.ed Name)
<br />?wner
<br />(Title)
<br />
<br />(j Sworn to and subscribed before me this
<br />. r~h(;ol f:111PWJ(IMJ
<br />,
<br />
<br />\'1
<br />
<br />day of
<br />
<br />n6fil>1IY
<br />
<br />4~i4ur{/
<br />
<br />, 20~, by
<br />
<br />(AFFIX NOTARY STAMP HERE)
<br />
<br />(i.
<br />MWt4JJ
<br />
<br />\\\\"""111'/ ~~tze: Nit{! Public - State of Florida
<br />,,\ SCOTT C. II;; PI': (;~ (J;l f-r t"TJr-Q..,
<br />~' ~~"...\SS;o... O..s>C ~ Print or Type Commissioned Name
<br />~ cr ..~~~ tv ~.. 0 ~ /
<br />~ .ae~iffiiiallrlflmw.n '%;.~ \~ V OR Produced Identification
<br />_ .~ ~..~r~. _
<br />: ~~e of l~n'i1TCatio;Frodied
<br />- · iO, '8 \U · ~-
<br />, ..-::" v V L\ Q). r"";:;; ....
<br />-:'1~~."ll f;)"'" SJ':-
<br />~ 'Y.t"- ...U"lRY 27.. ?;... cr ~
<br />", <"'l'{- ............ r:t><i; ~
<br />';'11 COUN-rt, \\",
<br />'II6IU"\\\
<br />
<br />3 of 7
<br />
|