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r � <br /> • <br /> SJNNY,51 . <br /> ANTI — KICKBACK <br /> � a Z <br /> a1 1= } a <br /> City of Sunny Isles Beach <br /> J a9 18070 Collins Avenue <br /> y,; =FLO + Sunny Isles Beach,FL 33160 <br /> c"y,oi.sus Telephone:(305)947-0606 Fax (305)949-3113 <br /> ANTI-KICKBACK AFFIDAVIT <br /> STATE OF FLORIDA ) <br /> COUNTY OF ) <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 [type of authority], for <br /> [name of party on behalf of whom instrument was <br /> executed]. <br /> AFFIX NOTARY STAMP HERE: <br /> Notary Public — State of Florida <br /> Print or Type Commissioned Name <br /> Personally Known OR Produced Identification <br /> Type of Identification Produced <br /> DECEMBER 28,2010 7 of 7 <br />