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6. Based on information and belief, the statement which I have marked below is true in relation to <br /> the entity submitting this sworn statement. [Indicate which statement applies] <br /> Neither the entity submitting this sworn statement, nor any of its officers, directors, <br /> executives, partners, shareholders, employees, members, or agents who are active in the <br /> management of the entity, nor any affiliate of the entity has been charged with and convicted of <br /> a public entity crime subsequent to July 1, 1989. <br /> The entity submitting this sworn statement, or one or more of its officers, directors, <br /> executives, partners, shareholders, employees, members, or agents who are active in the <br /> management of the entity, nor any affiliate of the entity has been charged with and convicted of <br /> a public entity crime subsequent to July 1, 1989. <br /> The entity submitting this sworn statement, or one or more of its officers, directors, <br /> executives, partners, shareholders, employees, members, or agents who are active in the <br /> management of the entity, nor any affiliate of the entity has been charged with and convicted of <br /> a public entity crime subsequent to July 1, 1989. However, there has been a subsequent <br /> proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings <br /> and the Final Order entered by the Hearing Officer of the State of Florida, Division of <br /> Administrative Hearings and the Final Order entered by the Hearing Officer determined that it <br /> was not in the public interest to place the entity submitting this sworn statement on the <br /> convicted vendor list. [attach a copy of the final order] <br /> I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR <br /> THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY <br /> ONLY AND, THAT THIS FORM IS.VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN <br /> WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC <br /> ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESH• D AMOUNT <br /> PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR CATEGORY TWO OF NY CHANGE <br /> IN THE INFORMATION CONTAINED IN THIS FORM. <br /> ,02 -at/ <br /> 11 [signature] <br /> Sworn to and subscribed before me this 19 day of t , 20 1.'4- <br /> Personally known <br /> OR Produced identification - L- - Notary Public - State of f-(Qn."4-o- <br /> My commission expires 9'e2.(o I )o I(o <br /> (Type of identification) JESSICA C.RAMOS <br /> NOTARY PUDLIC (Printed typed or stamped <br /> - STATE OF FLORIDA commissioned name of notary public) <br /> Ccmm4 EE195109 <br /> 0 - Expires 0/26/2016 <br /> 08/12 00402-2 11-4179 <br />