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SJNNY is,4.. PUBLIC ENTITY CRIMES r - • City of Sunny Isles Beach • L_ 18070 Collins Avenue 1F • D''. i,°a`° sem. Sunny Isles Beach,FL 33160 o. sus 'a� Telephone:(305)947-0606 Fax:(305)949-3113 ® SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a) FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES PUBLIC ENTITY CRIMES Pursuant to the provisions of paragraph (2) (a) of Section 287.133, Florida State Statutes - "A person or affiliate who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a Bid on a Contract to provide any goods or services to a public entity, may not submit a Bid on a Contract with a ® public entity for the construction or repair of a public building or public Work, may not submit Bids on leases of real property to a public entity, may not be awarded to perform Work as a Contractor, supplier, Sub-Contractor, or Consultant under a Contract with any public entity, and may not transact business with any public entity in excess ® of the threshold amount Category Two of Sec. 287.017, FS for thirty six months from the date of being placed on the convicted vendor list". THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER ® OFFICIAL AUTHORIZED TO ADMINISTER OATHS. 1. This sworn statement is submitted to City of Sunny Isles Beach by Jean L Lacaille Manager [pnnt individual's name and title) ® for Synerglace USA [pnrit name of entity submitting sworn statement) whose business address is: ® 2160 NE 191 Driver North Miami Beach FL 33179 40 ® and (if applicable) its Federal Employer Identification number(FEIN) is 97-3519258 ® (If the entity had no FEIN, include the Social Security Number of the individual signing this sworn statement: .) 2. I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a ® violation of any state or federal law by a person with respect to and directly related to the transaction of ® business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any Bid or Contract for goods or services to be provided to any ® public entity or an agency or political subdivision of any other state of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 3. I understand that "convicted" or"conviction" as defined in Para. 287.133(1)(b), Florida Statutes, means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any ® federal or state trail court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non-jury trial, or entry of a plea of guilty or nolo contendere. ® 4. I understand that an"affiliate" as defined in Para. 287.133(1)(a), Florida Statutes, means: a.) predecessor or successor of a person convicted of a public entity crime; or b.) Any entity under the control of any natural person who is active in the management of the entity ® and who has been convicted of a public entity crime. The term "affiliate" includes those officers, ® directors, executors, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair 2of7