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O� SJNNY !s<��d <br />� F <br />u` x <br />c,rr of $UN n�o <br />STATE OF FLORIDA ) <br />COUNTY OF Broward ) <br />ANTI - KICKBACK <br />City of Sunny Isles Beach <br />18070 Collins Avenue <br />Sunny Isles Beach, FL 33160 <br />Telephone: (305) 947 -0606 Fax: (305) 949 -3113 <br />ANTI - KICKBACK AFFIDAVIT <br />I, the undersigned, hereby duly sworn and deposed say that no portion of this sum herein Bid <br />will be paid to any employees of the City of Sunny Isles Beach or its elected officials as a <br />commission, kickback, reward or gift, directly or indirectly by me or any member of my firm or <br />by an officer of the corporation. <br />Title: <br />Mark Tomczyk, P.E. <br />Vice President <br />The foregoing instrument_ - w s- ackn wledged before me this day of <br />,i 20 b 0 Z [name <br />of de n], s 1C I /1 [type of authority], for <br />[name of party on behalf of whom instrument was <br />executed]. <br />AFFIX NOTARY STAMP HERE: <br />ry, MARLENE PINNOCK <br />MY COMMISSION # EE 142118 <br />. it EXPIRES: February 13, 2016 <br />Rf w' Bonded Thru Notary Public Uodetwriters <br />State of—Florida <br />t4i �I <br />Prilit ortype Commissioned Name <br />Personally Known OR Produced Identification <br />Type of Identification Produced <br />KEITH and SCHNARS, P.A. <br />FLORIDXS Pig LOCAL FIRM <br />PAGE 44 RFQ #12 -04 -05 <br />