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<br />PUBLIC ENTITY CRIMES
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<br />City of Sunny Isles Beach
<br />18070 conine Avenue
<br />Sunny Illes Beach. FL 83180
<br />Telophone: (300) 947.0"'. Fax: em) 949.3113
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<br />SWORN STATEMENT PURSUANT TO SEcnON 287.133(3)(a)
<br />FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
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<br />PUBLIC ENTITY CRIMES
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<br />Pursuant to the provisions of paragraph (2) (a) of Section 287.133, Florida State Statutes - "A person or affiliate
<br />who has been placed on the convlcted vllIldor list followfng a convlctlon ter a public entity crIme may not submit a
<br />Bid on a Contract to provlde any goods or services to a public entity, may not submit a Bid on a Contract with a
<br />pUblic entity for the constructfon or repair of a public building or public Work, may not submit Bids on leases of
<br />real property to 8 public entity, may not be awarded to perform Work as 8 Contractor, supplier, Sub-Contractor, or
<br />Consultant under a Contract with any public entity, and may not transact business with any public entity In excess
<br />of the threshold amount Category Two of Sec. 287.017, FS fOf thirty six months from the date of being placed on
<br />the convicted vendor Iisf'.
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<br />THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
<br />OFFICIAL Al1I'HORIZED TO ADMINISTER OATHS.
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<br />11.1.
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<br />This sworn stateme~ sub~llted to Cltv of Sunnv Isles Beach
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<br />by .1.k",wolE.~::je/cJ;; p.~.
<br />tor ~~';'~YIU""~~~on1(~til(t/:; ~o.
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<br />whosa b~lness address Is: /l /,,' d 1'2/..~ <;;? I J
<br />1't'l:L 6"01.,-1- ~?'(Af/_ ~vfL 011'<.
<br />hrf (av'de( r/,Je. . r---L. 53 jOb
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<br />... and (If applicable) Its Federal Employer Identification number (FEIN) Is f"~ _ 'J..(p If 0 ".I'oJ
<br />(If the entity had no FEIN, Include the Social Security Number of the Individual Signing this sworn
<br />statement .)
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<br />11.2. I understand that a "public entity crime" as defined In Paragraph 287. 133(1)(g), Florida Ststutes, means a
<br />violation of any state or federal law by a person with respect to and directly related to the transaction of
<br />business with any public entity or with an agency or political subdivision of any other state or with the
<br />United Slates, including, but not limited to, any BId or Contract for goods or services to be provlded to any
<br />public entity or an agency or political subdlvlslon of any other stat~ of the United States and Involvlng
<br />entitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, er material misreprasentallon.
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<br />11.3. I understand that "convicted" or "conviction" as defined in Para. 287.133(1 )(b), Florida Statutes, means a
<br />finding of guilt or a eOllviction of a public entity crime, wI1h or without an adjucllcatlon of guilt, In any
<br />federal or state trail court of racord ralatlng to charges brought by Indictment or Infonnatlon after July 1,
<br />1989, as a rasult of a Jury verdict, non-jury trial, or entry of a plea of guilty or nolo contendere.
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<br />11A. I understand that an "affiliate" as defined In Para. 287.133(1)(a), Florida Statutes, means:
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<br />a.)
<br />b.)
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<br />predecessor or successor of a person convicted of a public entity crime; or
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<br />Any entity under the control of any natural person who Is active in the management of the entity
<br />and who has been convicted of a public entity crime. The term "affiliate" Includes those officers,
<br />directors, executors. partners, shareholders, employees, members, and agents who are active in
<br />the management of an affiliate. The ownership by one person of shares constituting a controlling
<br />Interest In another person, or a pooling of equipment or income among persons when not for fair
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<br />OECD.\IlR2B,2010
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