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SUNNY 7S�F
<br /> !f PUBLIC ENTITY CRIMES
<br /> •
<br /> :r:.,.,:,• City of Sunny Isles Beach
<br /> -t_ 18070 Collins Avenue
<br /> S r ''•`F i oP� Sunny Isles Beach,FL 33160
<br /> o, s,,,,'` Telephone:(305)947-0606 Fax(305)949-3113
<br /> SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a)
<br /> FLORIDA STATUTES,ON PUBLIC ENTITY CRIMES
<br /> PUBLIC ENTITY CRIMES
<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 convicted vendor list following a conviction for a public entity crime may not submit a
<br /> Bid on a Contract to provide any goods or services to a public entity, may not submit a Bid on a Contract with a
<br /> public entity for the construction or repair of a public building or public Work, may not submit Bids on leases of
<br /> real property to a public entity, may not be awarded to perform Work as a 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 for thirty six months from the date of being placed on
<br /> the convicted vendor list".
<br /> THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
<br /> OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
<br /> 11.1. This sworn statement is submitted to City of Sunny Isles Beach
<br /> by J®atiete a. Cwwr�Aslt69�44
<br /> t not tndl ua s name and U e 0140
<br /> 04044 e046100,24 IIIDfor J pl �ft� ASM� I�a" teiT� a°nntname0 entity iIme t
<br /> whose business address is:
<br /> and(if applicable)its Federal Employer Identification number(FEIN)is 5 o INS 44010.42•
<br /> (If the entity had no FEIN, include the Social Security Number of the individual signing this sworn
<br /> statement: •)
<br /> 11.2. I understand that a"public entity crime"as defined in Paragraph 287.133(1)(g), Florida Statutes, 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 States,including, but not limited to,any Bid or Contract for goods or services to be provided to any
<br /> public entity or an agency or political subdivision of any other state of the United States and involving
<br /> antitrust,fraud,theft,bribery,collusion,racketeering,conspiracy,or material misrepresentation.
<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 conviction of a public entity crime, with or without an adjudication of guilt, In any
<br /> federal or state trail court of record relating to charges brought by indictment or information after July 1,
<br /> 1989,as a result of a jury verdict, non jury trial,or entry of a plea of guilty or nolo contendere.
<br /> 11.4. I understand that an"affiliate"as defined in Para.287.133(1)(a), Florida Statutes, means:
<br /> a.) predecessor or successor of a person convicted of a public entity crime;or
<br /> b.) 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
<br /> DECEMBER 28,2010 2 of 10
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