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<br /> • CONFLICT OF INTEREST
<br /> • SV, , /SSE
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<br /> <.O'`-n City of Sunny Isles Beach
<br /> 'l; I 18070 Collins Avenue
<br /> _ / Sunny Isles each,FL 33160
<br /> T 's.• �• �y P Telephone:(305)947-0606 Fax:(305)949-3113
<br /> ® F -FT.00. y
<br /> C rY 'NO
<br /> OF SUK CONFLICT OF INTEREST STATEMENT
<br /> ® The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State Statutes. Proposers
<br /> ® must disclose with their Bids,the name of any officer,director,partner,associate or agent who is also an officer or
<br /> ® employee of the City of Sunny Isles Beach or its agencies.
<br /> STATE OF FLORIDA
<br /> ® COUNTY OF ‘4. e...q,e?
<br /> O BEFORE ME,the undersigned authority, personally appearedO}'11 ( LC(CAA' ,
<br /> ® who was duly sworn,deposes,and states: ''
<br /> 1. I am the (,(%O PCuectI)' of S acs US with a local
<br /> office in 7A(,0 Nle )SA Or- f`Inr\-i t1A`c,,j o� 3?t�S and principal office
<br /> ® in Sclik , of .
<br /> O 2. The above named entity is submitting a Bid for the City of Sunny Isles Beach, Bid No. AlI o -0.L
<br /> O described as Sec,}-,,,-.JJ/ TC 1 c1 6,k. Q,n. . The Affiant has made diligent
<br /> ® inquiry and provides the information contained in his Affidavit based upon his own knowledge.
<br /> 0 3. The Affiant states that only one submittal for the above Bid is being submitted and that the above named
<br /> entity has no financial interest in other entities submitting Bids for the same project.
<br /> O 4. Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement,
<br /> ® participated in any collusion,or otherwise taken any action in restraints of free competitive pricing in connection
<br /> ® with the entity's submittal for the above Bid. This statement restricts the discussion of pricing data until the
<br /> ® completion of negotiations if necessary and execution of the Contract for this project.
<br /> ® 5. Neither the entity nor its affiliates,nor anyone associated with them,is presently suspended or otherwise
<br /> ineligible from participation in contract letting by any local,State,or Federal Agency.
<br /> ® 6. Neither the entity, nor its affiliates, nor anyone associated with them have any potential conflict of
<br /> ® interest due to any other clients,contracts,or property interests for this project.
<br /> ® 7. I certify that no member of the entity's ownership or management is presently applying for any employee
<br /> III position or actively seeking an elected position with the City of Sunny Isles Beach.
<br /> ® 8. I certify that no member of the entity's ownership or management,or staff has a vested interest in any
<br /> O aspect of the City of Sunny Isles Beach.
<br /> ® 9. In the event that a conflict of interest is identified in the provision of services, I,on behalf of the above
<br /> named entity,will immediately notify the City of Sunny Isles Beach.
<br /> ® Dated this $ day of tJ 00-ed� ,- e I ,20 11-.
<br /> ® /�;_—.. (,n L LO c A P4 (c c) Qui(
<br /> AFFIAN J P t or Type Name and Title
<br /> --®® Sworn to and subscribed before me this 0 day of KJ c50 ernes ,r ,20 n--.-
<br /> III
<br /> O-Personally Known,OR _ _
<br /> ® ❑ Produced Identification-Typ entification — — — .. _ ,. .. _ _
<br /> � . •'•�,,`"°`0,,,• PASCAL LASRY
<br /> NOTARY PUBLIC STATE OF FLORIDA Cir-41 MO y PubIM:State of Florida A
<br /> ® Gommtssion FF191856�xP 112 s / 1 g +,.-�--d,.?;° My Comm.Expires Jan 25,2019 I
<br /> • "%7"".
<br /> 5 of 7 f Bonded through National Notary Assn.
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