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s Ors � <br />sp X• sl0R1 tiw <br />Carr <br />Of W04 Sao <br />STATE OF FLORIDA ) <br />COUNTY OF ) <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 />By: <br />Title: <br />The foregoing instrument was acknowledged before me this day of <br />, 20 , by [name <br />of person], as <br />executed]. <br />AFFIX NOTARY STAMP HERE: <br />[type of authority], for <br />[name of party on behalf of whom instrument was <br />Notary Public — State of Florida <br />Print or Type Commissioned Name <br />Personally Known OR Produced Identification <br />Type of Identification Produced <br />OECEmsER 28, 2010 7 of 7 <br />