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HomeMy WebLinkAboutGreen Spaces Consultingc"'4 of 8i3+4 Or" DELIVER TO. REQUEST FOR City of Sunny Isles Beach QUALIFICATIONS OPENING: 2:30 P.M. City Clerk SECTION 6 Tuesday, August 11, 18070 Collins Avenue RESPONDENT SUBMITTAL 2020 Sunny Isles Beach, FL 33160 FORMS NOTE: City of Sunny Isles Beach is exempt from all taxes (Federal, State, and Local). Tax Exemption Certificate furnished upon request. Issued by: Purchasing Agent Date Issued: This Qualification Submittal Genesis Cuevas Wednesday, July 8, Consists of all required forms, 2020 including SF330, Questionnaires, Acknowledgements and Affidavits Submissions are subject to the Terms and Conditions of this Request for Qualifications and the accompanying Submittal. Such other contract provisions, specifications, drawings or other data as are attached or incorporated by reference in the Submittal, will be received at the office of the City Clerk at the address shown above until the above stated time and date, and at that time, publicly opened for furnishing services described in the accompanying Submittal Requirement. RFQ No. 20-07-01 Continuing Contract for Professional Services CCNA Commodity Code(s); FIrm Name AFFIDA VITS FAILURE TO SIGN PAGE 38 OF SECTION 6 QUALIFICATION SUBMITTAL WILL RENDER YOUR SUBMISSION NON-RESPONSIVE City of Sunny Isles Beach I Request for Qualifications No. 20-07-01 6.1 ACKNOWLEDGEMENT FORM NAME OF COMPANY: LLQ'cI v7kC,` �� G (Name of company submitting RFQ) CHECK CATEGORY (CATEGORIES) YOU ARE APPLYING FOR: 1- ARCHITECTS 2- CIVIL ENGINEERS 3- ELECTRICAL ENGINEERS 4- SURVEYORS AND MAPPING i/ 5- LEAK DETECTION STUDIES 6- MECHANICAL, HVAC & PLUMBING ENGINEERS_ 7 - GEOTECHNICAL 8 — STRUCUTRAL ENGINEERS 9 — ENVIRONMENTAL ENGINEERS 10. CONSTRUCTION ENGINEERING AND INSPECTION (CEI) SERVICES City of Sunny Isles Beach I Request for Qualifications No. 20-07-01 REQUIRED FORMS PRIME FIRM �, �• Fk-'A. yk,. Role Name of Individual Number of Years' Education, Degree Assigned to Project Experience Other Key Member' REFERENCES City of Sunny Isles Beach Request for Qualifications No. 20-07-01 ACKNOWLEDGEMENT OF ADDENDA INSTRUCTIONS: COMPLETE PART I OR PART II, WHICHEVER APPLIES PART I: LIST BELOW ARE THE DATES OF ISSUE FOR EACH ADDENDUM RECEIVED IN CONNECTION WITH THIS RFC) PART II: Addendum #1, Dated Addendum #2, Dated Addendum #3, Dated Addendum #4, Dated Addendum #6, Dated Addendum #6, Dated Addendum #7, Dated Addendum #8, Dated ❑ NO ADDENDUM WAS RECEIVED IN CONNECTION WITH THIS RFQ FIRM NAME: AUTHORIZED SIGNATURE: �� DATE: TITLE OF OFFICER: ®G6 "y 2— City of Sunny Isles Beach I Request for Qualifications No. 20-07-01 �r�rV OF SUN PSV 'I4' OF wt-' RESPONDENT SUBMITTAL FORM RFQ 20-07-01 Continuing Professional Consulting Services (CCNA) The undersigned Firm proposes and agrees, if this submission is accepted, to enter into an agreement with the City of Sunny Isles Beach to perform and furnish all Services as specified or indicated in the Contract Documents. The Firm accepts all of the terms and conditions of this Request for Qualifications. This Bid will remain subject to acceptance for 90 days after the day of Bid opening. The Firms agrees to sign and submit the Agreement and other documents as required by the Bidding Requirements within ten days after the date of the City's Notice of Award. In submitting this response, the Firm represents, as more fully set forth in the Agreement, that: ■ The Firm has familiarized himself/herself with the nature and extent of the Contract Documents, Work, site, locality, and all local conditions and Law and Regulations that in any manner may affect cost, progress, performance, or furnishing of the Work. ■ The Firm has studied carefully all reports and drawings of subsurface conditions and drawings of physical conditions. ■ The Firm has given the City written notice of all conflicts, errors, discrepancies that it has discovered in the Contract Documents and the written resolution thereof by City is acceptable to the Firm. ■ This solicitation is genuine and not made in the interest of or on behalf of any undisclosed person, firm or corporation and is not submitted in conformity with any agreement or rules of any group, association, organization, or corporation; the Firm has not directly or indirectly induced or solicited any other Firms to submit a false or sham Bid; the Firm has not solicited or induced any person, firm or corporation to refrain from Bidding; and Firm has not sought by collusion to obtain for itself any advantage over any other Firms or over the City. The City and the successful Firm will establish completion times for the services described in this Request for Qualifications and the successful Firm agrees that the services will be completed within the time frames agreed upon and stipulated in the individual Notice to Proceed. City of Sunny Isles Beach I Request for Qualifications No. 20-07-01 '?4' of MAIL h� Firm Name: r,4'e, S Street 'l o Mailing Address (if different): Telephone No. Sb� �.?y�� Fax No. Email Address:/ . Oizw S +r1-,5 #6 No. 8- �/� O . e -4 --or- *"By s/yn/ng this document the Responder agrees to a// Terms Signature: (Signature) f authorizea'alfty�it��/ Print Name: Title: THE EXECUTION OF THIS FORM CONSTITUTES THE UNEQUIVOCAL OFFER OF FIRM TO BE BOUND BY THE TERMS OF ITS SUBMISSION. FAILURE TO SIGN THIS SOLICITATION WHERE INDICATED ABOVE BY AN AUTHORIZED REPRESENTATIVE SHALL RENDER THE SUBMISSION NON-RESPONSIVE. THE CITY MAY, HOWEVER, IN ITS SOLE DISCRETION, ACCEPT ANY SUBMISSION THAT INCLUDES AN EXECUTED DOCUMENT, WHICH UNEQUIVOCALLY BINDS THE FIRM TO THE TERMS OF ITS OFFER. City of Sunny Isles Beach I Request for Qualifications No. 20-07-01 STATE OF FLORIDA ) COUNTY OF OKA W69)) ANTI -KICKBACK City of Sunny Isles Beach 18070 Collins Avenue Sunny Isles Beach, FL 33160 Telephone: (305) 947-0606 Fax: (305) 949-3113 ANTI -KICKBACK AFFIDAVIT I, the undersigned, hereby duly sworn and deposed say that no portion of this sum herein Bid will be paid to any employees of the City of Sunny Isles Beach or its elected officials as a commission, kickback, reward or gift, directly or indirectly by me or any member of my firm or by an officer of the corporation. The foregoing Nt)&t�T , of personl, as -A executed]. By: Title: 6'2 .. Aft' AL instrument was acknowledged before me this day of 202, by , t7© FREtrwAk) [name )()Tr+(Z % P1)/3o/_ [type of authority], for S11lu= rname of party on behalf of whom instrument was AFFIX NOTARY STAMP HERE: IMI NeQ WNW � �r My eaTM+lr�on oar.. o Qommla M Na QQ 910167 Notary Pu li — State of Florida F U:(+919 Print or Type Commissioned Name Personally Known OR Produced Identification Type of Identification Produced (?j1)4 't>MOE s Li i GOSE DECEMBER 28, 2010 %4 NY I.Tt a. F C'rr OF SUN\�V STATE OF FLORIDA ) COUNTY OFWtfl) ANTI -KICKBACK City of Sunny Isles Beach 18070 Collins Avenue Sunny Isles Beach, FL 33160 Telephone: (305) 947-0606 Fax: (305) 949-3113 ANTI -KICKBACK AFFIDAVIT I, the undersigned, hereby duly sworn and deposed say that no portion of this sum herein Bid will be paid to any employees of the City of Sunny Isles Beach or its elected officials as a commission, kickback, reward or gift, directly or indirectly by me or any member of my firm or by an officer of the corporation. The foregoing N)&Lo�'T of Dersonl. as J executed]. instrument was acknowledged before me this day of 202Q, byj?-ta.21F��� X72 -r_rvlA0 (name ) t)Ti w \,- -PwSL:i/_ [type of authority), for \SJ;E=- [name of party on behalf of whom instrument was AFFIX NOTARY STAMP HERE: 010Z l9ew.raar►Wn,M SWeelft Mremomb 80"ONVAM a own"MNa0*910187 Notary Pu li — State of Florida &ZANV-12 Print or Type Commissioned Name Personally Known OR Produced Identification Type of Identification Produced G.0Qtin4 t?M-6 `z Lt i e0S_g DECEMBER28,2010 �SVp1NY IS�Fd A. .aSas.:+3 p yF �9F' Ft09- Oi suN �`a0 STATE OF FLORIDA ) COUNTY OFW69) ANTI -KICKBACK City of Sunny Isles Beach 18070 Collins Avenue Sunny Isles Beach, FL 33160 Telephone: (305) 947.0606 Fax: (305) 949-3113 ANTI -KICKBACK AFFIDAVIT I, the undersigned, hereby duly sworn and deposed say that no portion of this sum herein Bid will be paid to any employees of the City of Sunny Isles Beach or its elected officials as a commission, kickback, reward or gift, directly or indirectly by me or any member of my firm or by an officer of the corporation. The foregoing instrument wa acknowledged before me this day of ►,QCs `i' 20 by , 2 120 1= rWA0 [name of person], as A)QT-ARPr>M:i/_ [type of authority), for Adagg 65 a Lno3wi [name of party on behalf of whom instrument was executed]. AFFIX NOTARY STAMP HERE: �,«• 111161101111110. "on" �M 00r -+�rol son OM AN a Coit7n W=fteemolar Notary Pu li —State of Florida &1A!)d9,QPQ V4492 Print or Type Commissioned Name Personally Known OR Produced Identification Type of Identification Produced ilnA © ,,L9t Lt i C-Ost` DECEMBER28,2010 oR_SV14NY IS���e 9 FLOS 6�r SUN STATE OF FLORIDA ) COUNTY OFhatk) ANTI --KICKBACK City of Sunny Isles Beach 18070 Collins Avenue Sunny Isles Beach, FL 33160 Telephone: (305) 947-0606 Fax: (305) 949-3113 ANTI -KICKBACK AFFIDAVIT I, the undersigned, hereby duly sworn and deposed say that no portion of this sum herein Bid will be paid to any employees of the City of Sunny Isles Beach or its elected officials as a commission, kickback, reward or gift, directly or indirectly by me or any member of my firm or by an officer of the corporation. The foregoing Do&L-y'T of versonl. as executed]. i y. instrument wat_,,acknowledged before me this day of 20�, by - �f20 Ella n44k l [name )_T, m— V, P&1361 - [type of authority], for S6r-- [name of party on behalf of whom instrument was AFFIX NOTARY STAMP HERE: ,�" Iii�aaa �, �Mra�w�ona�eoedna� °' Coma�hebn Noy 00 p10t87' Notary Pu li -State of Florida alh!)dR12 J::_(2l:EEn44Q Print or Type Commissioned Name Personally Known OR Produced Identification ✓ Type of Identification Produced 94(?-) i0A DM iEota_ Lt I c -Os DECEMBER 28, 2010 .SUNNY !S�@ � n u � x S, „ �, yF y9x ",.f LOT' 4 of sun STATE OF FLORIDA COUNTY OFW69)) ANTI -KICKBACK City of Sunny Isles Beach 18070 Collins Avenue Sunny Isles Beach, FL 33160 Telephone: (305) 947-0606 Fax: (305) 949-3113 ANTI -KICKBACK AFFIDAVIT I, the undersigned, hereby duly sworn and deposed say that no portion of this sum herein Bid will be paid to any employees of the City of Sunny Isles Beach or its elected officials as a commission, kickback, reward or gift, directly or indirectly by me or any member of my firm or by an officer of the corporation. � The foregoing i of Dersonl. as J executed]. B -- Y• Title: ® �c instrument wa acknowledged before me this day of ZOO, by ---4�xA 2 am FIZEL- nou [name )yTir+u Poi3 iz [type of authority], for tiS6E- [name of party on behalf of whom instrument was AFFIX NOTARY STAMP HERE: ill�laarr stee.dF*W S►eawaonnoe a Cammi�eton Noy t�0 ptOt87 C�_ F_'4 Notary Pu li — State of Florida &L"!)ago J:2 E_ a&v Print or Type Commissioned Name Personally Known OR Produced Identification Ll� Type of Identification Produced q,,0Qjing U i C -OS DECEWER 28, 2070 S�)NNgYdpp is,e NON -COLLUSION AFFIDAVIT City of Sunny Isles Beach 18070 Collins Avenue Sunny Isles Beach, FL 33160 or SUN ATelephone: (305) 947-0606 Fax: (305) 949-3113 STATE OF FLORIDA ) COUNTY O�" The undersigned being first duly sworn as provided by law, deposes, and says: This Affidavit is made with the knowledge and intent that it is to be filed with the City of Sunny Isles Beach City Commission and that it will be relied upon by said County, in any consideration which may give to and any action it may take with respect to this Bid. The undersigned is authorized to make this Affidavit on behalf ofXy 1, ov y� LL G (a a of Corporation, Partnership, In vidual, etc.) a, Z/ , formed under the laws of �� (Type of Business) (State) of which he is (-)�F �i ' \ (Sole Owner, Partner, President, etc.) Neither the undersigned nor any person, firm, or corporation named in above Paragraph 10.2, nor anyone else to the knowledge of the undersigned, have themselves solicited or employed anyone else to solicit favorable action for this Bid by the City, also that no head of any department or employee therein, or any officer of the City of Sunny Isles Beach, Florida is directly interested therein. This Bid is genuine and not collusive or a sham; the person, firm or corporation named above in Paragraph 10.2 has not colluded, conspired, connived or agreed directly or indirectly with any proposers or person, firm or corporation, to put in a sham Bid, or that such person, firm or corporation, shall refrain from Bidding, and has not in any manner, directly or indirectly, sought by agreement or collusion, or communication or conference with any person, firm or corporation, to fix the prices of said Bid or Bids of any other proposers; and all statements contained in the Bid or Bids described above true; and further; neither the undersigned, nor the person, firm or corporation named above in Paragraph 10.2, has directly or indirectly submitted said Bid or the contents thereof, or divulged information or data relative thereto, to any association or to any member or agent thereof. AFFIANT'S TITLE TA EN, SWORN AND SUBSCRIBED TO BEFORE ME this day of a�r 20— Personally Known or Produced Identification � ; Type of identification F1.111219* p 2t (31;7fj5 L-1 J ELNX & (Affix seal here) EdN�ln! Q wllnnq "of Raft M�►eemmroelott Dow OVO4/1 � � NR. Qp p10187 DECEMBER 28, 2010 rf o` S�NNY 4P NON -COLLUSION AFFIDAVIT u rs 2 City of Sunny Isles Beach '+ 99) 18070 Collins Avenue 'S"p P `o?. -:1 Sunny Isles Beach, FL 33160 cl rr ov su" NO Telephone: (305) 947-0606 Fax: (305) 949-3113 STATE OF FLORIDA ) COUNTY OF �A*4441 The undersigned being first duly sworn as provided by law, deposes, and says: This Affidavit is made with the knowledge and intent that it is to be filed with the City of Sunny Isles Beach City Commission and that it will be relied upon by said County, in any consideration which may give to and any action it may take with respect to this Bid. The undersigned is authorized to make this Affidavit on behalf of, (a —eof Corporation, Partnership, Inblvidual, etc.) a, , formed under the laws of (Type of Business) (State) of which he is 0[ (Sole Owner, Partner, President, etc.) Neither the undersigned nor any person, firm, or corporation named in above Paragraph 10.2, nor anyone else to the knowledge of the undersigned, have themselves solicited or employed anyone else to solicit favorable action for this Bid by the City, also that no head of any department or employee therein, or any officer of the City of Sunny Isles Beach, Florida is directly interested therein. This Bid is genuine and not collusive or a sham; the person, firm or corporation named above in Paragraph 10.2 has not colluded, conspired, connived or agreed directly or indirectly with any proposers or person, firm or corporation, to put in a sham Bid, or that such person, firm or corporation, shall refrain from Bidding, and has not in any manner, directly or indirectly, sought by agreement or collusion, or communication or conference with any person, firm or corporation, to fix the prices of said Bid or Bids of any other proposers; and all statements contained in the Bid or Bids described above true; and further; neither the undersigned, nor the person, firm or corporation named above in Paragraph 10.2, has directly or indirectly submitted said Bid or the contents thereof, or divulged information or data relative thereto, to any association or to any member or agent thereof. AFF AN J AFFIANT'S TITLE ds— TA EN, SWORN AND SUBSCRIBED TO BEFORE ME this/� day of (�[ �� 2 Personally Known or Produced Identification Y Type of identification �1 �^iOjVArzr Lit D5 L1115-- c (Affix seal here) I>�aaan oa0ar�zs ��� � ti1018T DECEMBER26,2010 SJ�yNY tst6 O� Je F y NON -COLLUSION AFFIDAVIT � n City of Sunny Isles Beach ft"aY2 a' a • 181170 Collins Avenue Sunny Isles Beach, FL 33160 hyf' 99�• FL�R` 4� of su" *a� Telephone: (305) 947-0606 Fax: (305) 949-3113 STATE OF FLORIDA ) COUNTY OF The undersigned being first duly sworn as provided by law, deposes, and says: This Affidavit is made with the knowledge and intent that it is to be filed with the City of Sunny isles Beach City Commission and that it will be relied upon by said County, in any consideration which may give to and any action it may take with respect to this Bid. The undersigned is authorized to make this Affidavit on behalf of, (R—ai6e of Corporation, Partnership, in vidual, etc.) a '4�11, formed under the laws of e4 (Type of Business) (State) of which he is�lX��'` (Sole Owner, Partner, President, etc.) Neither the undersigned nor any person, firm, or corporation named in above Paragraph 10.2, nor anyone else to the knowledge of the undersigned, have themselves solicited or employed anyone else to solicit favorable action for this Bid by the City, also that no head of any department or employee therein, or any officer of the City of Sunny Isles Beach, Florida Is directly interested therein. This Bid is genuine and not collusive or a sham; the person, firm or corporation named above in Paragraph 10.2 has not colluded, conspired, connived or agreed directly or Indirectly with any proposers or person, firm or corporation, to put in a sham Bid, or that such person, firm or corporation, shall refrain from Bidding, and has not in any manner, directly or indirectly, sought by agreement or collusion, or communication or conference with any person, firm or corporation, to fix the prices of said Bid or Bids of any other proposers; and all statements contained in the Bid or Bids described above true; and further; neither the undersigned, nor the person, firm or corporation named above in Paragraph 10.2, has directly or indirectly submitted said Bid or the contents thereof, or divulged information or data relative thereto, to any association or to any member or agent thereof. AFFIAN AFFIANT'S TITLE V TA EN, SWORN AND SUBSCRIBED TO BEFORE ME this day of /, <-7— 2 WX Personally Known or Produced Identification Type of identification �� ^ !1" Alt t3; n' LILEL'X& (Affix seal here) I>�w.faalln &**" Mum DECEMSER26,2010 SJNNY +s�F o�` seg NON -COLLUSION AFFIDAVIT ,i City of Sunny Isles Beach ' 18070 Collins Avenue Sunny Isles Beach, FL 33160 r�ry or sur " Telephone: (305) 947-0606 Fax: (305) 949-3113 STATE OF FLORIDA ) COUNTY OF The undersigned being first duty sworn as provided by law, deposes, and says: This Affidavit is made with the knowledge and intent that it is to be filed with the City of Sunny Isles Beach City Commission and that it will be relied upon by said County, in any consideration which may give to and any action it may take with respect to this Bid. The undersigned is authorized to make this Affidavit on behalf of, (95'We' of Corporation, Partnership, In vidual, etc.) a, (!:�- , formed under the laws of (Type of Business) (State) of which he is 0 �'\ (Sole Owner, Partner, President, etc.) Neither the undersigned nor any person, firm, or corporation named in above Paragraph 10.2, nor anyone else to the knowledge of the undersigned, have themselves solicited or employed anyone else to solicit favorable action for this Bid by the City, also that no head of any department or employee therein, or any officer of the City of Sunny Isles Beach, Florida is directly interested therein. This Bid is genuine and not collusive or a sham; the person, firm or corporation named above in Paragraph 10.2 has not colluded, conspired, connived or agreed directly or indirectly with any proposers or person, firm or corporation, to put in a sham Bid, or that such person, firm or corporation, shall refrain from Bidding, and has not in any manner, directly or indirectly, sought by agreement or collusion, or communication or conference with any person, firm or corporation, to fix the prices of said Bid or Bids of any other proposers; and all statements contained in the Bid or Bids described above true; and further; neither the undersigned, nor the person, firm or corporation named above in Paragraph 10.2, has directly or indirectly submitted said Bid or the contents thereof, or divulged information or data relative thereto, to any association or to any member or agent thereof. AFF AN S AFFIANT'S TITLE TA EN, SWORN AND SUBSCRIBED TO BEFORE ME this L dayof 2 Personally Known or Produced Identificationy ; Type of identification Fi.. oJ24.Alt - — LI(�C (Affix seal here) p1 � Lrdw�IdQFt�m�t IIoRF1oI�t 00J0411a23 �►MY c� �alo�sr DECEMBER 28, 2010 SUNNY J'1�F O� y�r JeF. NON -COLLUSION AFFIDAVIT City of Sunny Isles Beach 18070 Collins Avenue 4•+.'99). FLOP"OP y'�r Sunny Isles Beach, FL 33160 can Fav Telephone: (305) 947-0606 Fax: (305) 949-3113 STATE OF FLORIDA ) COUNTY OF The undersigned being first duly swom as provided by law, deposes, and says: This Affidavit Is made with the knowledge and intent that it is to be filed with the City of Sunny Isles Beach City Commission and that it will be relied upon by said County, in any consideration which may give to and any action it may take with respect to this Bid. The undersigned is authorized to make this Affidavit on behalf of, " 5-Z.tJ 14 LL G (a a of Corporation, Partnership, Individual, etc.) a 4e�ll , formed under the laws of (Type of Business) (State) of which he Is j'd 'i '\ (Sole Owner, Partner, President, etc.) Neither the undersigned nor any person, firm, or corporation named in above Paragraph 10.2, nor anyone else to the knowledge of the undersigned, have themselves solicited or employed anyone else to solicit favorable action for this Bid by the City, also that no head of any department or employee therein, or any officer of the City of Sunny Isles Beach, Florida Is directly interested therein. This Bid is genuine and not collusive or a sham; the person, firm or corporation named above in Paragraph 10.2 has not colluded, conspired, connived or agreed directly or indirectly with any proposers or person, firm or corporation, to put in a sham Bid, or that such person, firm or corporation, shall refrain from Bidding, and has not in any manner, directly or indirectly, sought by agreement or collusion, or communication or conference with any person, firm or corporation, to fix the prices of said Bid or Bids of any other proposers; and all statements contained in the Bid or Bids described above true; and further; neither the undersigned, nor the person, firm or corporation named above in Paragraph 10.2, has directly or indirectly submitted said Bid or the contents thereof, or divulged information or data relative thereto, to any association or to any member or agent thereof. AFF A r AFFIANT'S TITLE L�) i'H TA EN, SWORN AND SUBSCRIBED TO BEFORE ME this /_ day of Personally Known or Produced Identificationy Type of Identification FL.DS(!1Q& Alfyaz!> L1 i &L'X & (Affix seal here) V Q tAOR .4, i e1111111111 00104=11 p10187 DECEMBER28,2010 NNY !S CONFLICT OF INTEREST City of Sunny Isles Beach 18070 Collins Avenue sfi 9' • F tomo s� Sunny Isles Beach, FL 33160 c`'r or suo aTelephone: (305) 947-0606 Fax: (305) 949-3113 CONFLICT OF INTEREST STATEMENT The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State Statutes. Proposers must disclose with their Bids, the name of any officer, director, partner, associate or agent who is also an officer or employee of the City of Sunny Isles Beach or its agencies. STATE OF FLORIDA COUNTY OF BEFORE ME, the undersigned authority, personally appeared/4L who was duly sworn, deposes, and states: 18.1. 1 am the A) —1 P14,13 Lt of with a local office in G/ and principal office in 18.2. The above named entity is submitting a Bid for the City of Sunny Isles Beach, RFQ No. � 0 • o 7-0/ described as: RFQ Professional services. The Affiant has made diligent inquiry and provides the information contained in this Affidavit based upon his own knowledge. 18.3 The Affiant states that only one submittal for the above Bid is being submitted and that the above named entity has no financial interest in other entities submitting Bids for the same project. 18.4 Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraints of free competitive pricing in connection with the entity's submittal for the above Bid. This statement restricts the discussion of pricing data until the completion of negotiations if necessary and execution of the Contract for this project. 18.6 Neither the entity nor its affiliates, nor any one associated with them, is presently suspended or otherwise ineligible from participation in contract letting by any local, State, or Federal Agency. 18.6 Neither the entity, nor its affiliates, nor any one associated with them have any potential conflict of interest due to any other clients, contracts, or property interests for this project. 18.71 certify that no member of the entity's ownership or management is presently applying for any employee position or actively seeking an elected position with the City of Sunny Isles Beach. 18.81 certify that no member of the entity's ownership or management, or staff has a vested interest in any aspect of the City of Sunny Isles Beach. 18.9 In the event that a conflict of interest is identified in the provision of services, I, on behalf of the above named entity, will immediately notify the City of Sunny Isles Beach. 'fH �vtl�f21G 11�N5� this %1 day of L±U o p s — .2020. -^�•—,�Ieu.1 �I ra>/Lvtr� ' '-rrl�✓ -- Ni�Ti�Ff7_� p�iE..i L Print or Type Name and Titl�j��� 2 i Swornp and subscribed before me this W— day of &.?— .2020. Personally Known OR VProduced Identification ;Type of Identification F�210A WQ�ZS L1 MrJ3ux — NOTARY PUBLIC STATE OF FLORIDA �4-r �acfFlorldlrl �i�.fyy �pnrr�ton �� 09b4R028 �w� 'tgnrnlpton No.ORi 91018: DECEMBER 28, 2010 � yu�sNr +Stir CONFLICT OF INTEREST U �. z City of Sunny Isles Beach 18070 Collins Avenue Clt PLO 0 ; Sunny Isles Beach, FL 33160 c,rr of sur+ "" Telephone: (305) 947-0606 Fax: (306) 949-3113 CONFLICT OF INTEREST STATEMENT The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State Statutes. Proposers must disclose with their Bids, the name of any officer, director, partner, associate or agent who is also an officer or employee of the City of Sunny Isles Beach or its agencies. STATE OF FLORIDA COUNTY OF i BEFORE ME, the undersigned authority, personally appeared /1� Lbw ,who was duly sworn, deposes, and states: 18.1. 1 am the Y 64 L`t of with a local office in _ L g2 i and principal office in 18.2. The above named entity is submitting a Bid for the City of Sunny Isles Beach, RFQ No. 2 ® -07-9/ described as: RFQ Professional services. The Affiant has made diligent inquiry and provides the information- contained in this Affidavit based upon his own knowledge. 18.3 The Affiant states that only one submittal for the above Bid is being submitted and that the above named entity has no financial interest in other entities submitting Bids for the same project. 18A Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraints of free competitive pricing in connection with the entity's submittal for the above Bid. This statement restricts the discussion of pricing data until the completion of negotiations if necessary and execution of the Contract for this project. 18.5 Neither the entity nor its affiliates, nor any one associated with them, is presently suspended or otherwise ineligible from participation in contract letting by any local, State, or Federal Agency. 18.6 Neither the entity, nor its affiliates, nor any one associated with them have any potential conflict of interest due to any other clients, contracts, or property interests for this project. 18.71 certify that no member of the entity's ownership or management is presently applying for any employee position or actively seeking an elected position with the City of Sunny Isles Beach. 18.81 certify that no member of the entity's ownership or management, or staff has a vested interest in any aspect of the City of Sunny Isles Beach. 18.9 In the event that a conflict of interest is identified in the provision of services, 1, on behalf of the above named entity, will immediately notify the City of Sunny Isles Beach. AIA M A�fZ 1L l�kVS� or Type Name and TitI���C Sworn p and subscribed before me this day of , ��sr- , 2020. O / Personally Known OR f (9/ Produced Identification ; Type of Identification a4.12)VA ;Dd,133ZS L/L SL NOTARY PUBLIC STATE OF FLORIDA 114w�1dQfFeenr111 s>ItabdFlorldti #Ap tbrllmbelorr 0lIVNlRD23 a O"mft lonNo.00010187 DECEM86R20,2010 A. SV�^ jstF�eF � 9 CONFLICT OF INTEREST U City of Sunny Isles Beach �> r 18070 Collins Avenue '� p9' • f � C, ySunny Isles Beach, FL 33160 c`'r oo S.K''Telephone: (305) 947-0606 Fax: (305) 949-3113 CONFLICT OF INTEREST STATEMENT The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State Statutes. Proposers must disclose with their Bids, the name of any officer, director, partner, associate or agent who is also an officer or employee of the City of Sunny Isles Beach or its agencies. STATE OF FLORIDA COUNTY OF BEFORE ME, the undersigned authority, personally appeared/#R< L.agt E who was duly sworn, deposes, and states: 18.1. 1 am the AkMgy 64Q- of with a local office in IWIWt11,and principal office in timuld 18.2. The above named entity is submitting a Bid for the City of Sunny Isles Beach, RFQ No. �0 ' ® ®described as: RFQ Professional services. The Affiant has made diligent inquiry and provides the information con�aired in this Affidavit based upon his own knowledge. 18.3 The Affiant states that only one submittal for the above Bid is being submitted and that the above named entity has no financial interest in other entities submitting Bids for the same project. 18A Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraints of free competitive pricing in connection with the entity's submittal for the above Bid. This statement restricts the discussion of pricing data until the completion of negotiations if necessary and execution of the Contract for this project. 18.5 Neither the entity nor its affiliates, nor any one associated with them, is presently suspended or otherwise ineligible from participation in contract letting by any local, State, or Federal Agency. 18.6 Neither the entity, nor its affiliates, nor any one associated with them have any potential conflict of interest due to any other clients, contracts, or property interests for this project. 18.71 certify that no member of the entity's ownership or management is presently applying for any employee position or actively seeking an elected position with the City of Sunny Isles Beach. 18.81 certify that no member of the entity's ownership or management, or staff has a vested interest in any aspect of the City of Sunny Isles Beach. 18.9 In the event that a conflict of interest is identified in the provision of services, I, on behalf of the above named entity, will immediately notify the City of Sunny Isles Beach. 7%'t k4af2llL IAA) -4r - or Type Name and Titl2:P��e 2 Sworn and subscribed before me this -A/L day of�/, l,�T , 2020. O Personally Known OR T Produced Identification _;Type of Identification Wer NOTARY PUBLIC STATE OF FLORIDA 19dwandQ.lFilMltN Staaof rAft ��#AyOonlM�ebnftwo 0l a� >Conrn6alonN0.l;iGltO1B7 DECEMBER 28, 20W Y SJtANY rs�Ff `e9 CONFLICT OF INTEREST City of Sunny Isles Beach 18070 Collins Avenue so"Sunny Isles Beach, FL 33160 c`'* or suµ " Telephone: (305) 947-0606 Fax: (305) 949-3113 CONFLICT OF INTEREST STATEMENT The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State Statutes. Proposers must disclose with their Bids, the name of any officer, director, partner, associate or agent who is also an officer or employee of the City of Sunny Isles Beach or its agencies. STATE OF FLORIDA / COUNTY OF �,j�� BEFORE ME, the undersigned authority, personally appeared ffl< L.l gbE— , who was duly sworn, deposes, and states: 18.1. 1 am the V,6401 -of 10EUA 6&3 with a local office in 4044d,_7 and principal office in 18.2. The above named entity is submitting a Bid for the City of Sunny Isles Beach, RFQ No. 20 ' 07— D described as: RFQ Professional services. The Affiant has made diligent inquiry and provides the information con ained in this Affidavit based upon his own knowledge. 18.3 The Affiant states that only one submittal for the above Bid is being submitted and that the above named entity has no financial interest in other entities submitting Bids for the same project. 18.4 Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraints of free competitive pricing in connection with the entity's submittal for the above Bid. This statement restricts the discussion of pricing data until the completion of negotiations if necessary and execution of the Contract for this project. 18.6 Neither the entity nor its affiliates, nor any one associated with them, is presently suspended or otherwise ineligible from participation in contract letting by any local, State, or Federal Agency. 18.6 Neither the entity, nor its affiliates, nor any one associated with them have any potential conflict of interest due to any other clients, contracts, or property interests for this project. 18.71 certify that no member of the entity's ownership or management is presently applying for any employee position or actively seeking an elected position with the City of Sunny Isles Beach. 18.81 certify that no member of the entity's ownership or management, or staff has a vested interest in any aspect of the City of Sunny Isles Beach. 18.91n the event that a conflict of interest is identified in the provision of services, 1, on behalf of the above named entity, will immediately notify the City of Sunny Isles Beach. 7,1W n ►viA-fL1L L,MVS� this_ / f day of 2020. or Type Name and Titlbj ,Z- d Sworn P and subscribed before me this _a_ day of a /, l� 4cy _ .2020. O / Personally Known OR t Produced Identification ;Type of Identification F-Lt2210A NOTARY PUBLIC STATE OF FLORIDA Q fIM111N +9'� IBtrllt•o1FID11d11 �.#Ay Oonrntsr�bn B4+�e� 081bAl2D28 �a� 't;OirNninlonW0.ft0910181 DECEmsER28,2010 KNy �S 1d ' CONFLICT OF INTEREST City of Sunny Isles Beach 18070 Collins Avenue hyf . FtoP`° y�e Sunny Isles Beach, FL 33160 �,r ' oo SUO "''� Telephone: (305) 947-0606 Fax: (305) 949-3113 CONFLICT OF INTEREST STATEMENT The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State Statutes. Proposers must disclose with their Bids, the name of any officer, director, partner, associate or agent who is also an officer or employee of the City of Sunny Isles Beach or its agencies. STATE OF FLORIDA COUNTY OF BEFORE ME, the undersigned authority, personally appeared I L.I}j1Sb , who was duly sworn, deposes, and states: 18.1. 1 am the Ak `i; 1' L: of with a local office in 4114gQ Kbam 1.�_— and principal office in 18.2. The above named entity is submitting a Bid for the City of Sunny Isles Beach, RFQ No. � O --07-0/ described as: RFQ Professional services. The Affiant has made diligent inquiry and provides the information con ained in this Affidavit based upon his own knowledge. 18.3 The Affiant states that only one submittal for the above Bid is being submitted and that the above named entity has no financial interest in other entities submitting Bids for the same project. 18A Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraints of free competitive pricing in connection with the entity's submittal for the above Bid. This statement restricts the discussion of pricing data until the completion of negotiations if necessary and execution of the Contract for this project. 18.6 Neither the entity nor its affiliates, nor any one associated with them, is presently suspended or otherwise ineligible from participation in contract letting by any local, State, or Federal Agency. 18.6 Neither the entity, nor its affiliates, nor any one associated with them have any potential conflict of interest due to any other clients, contracts, or property interests for this project. 18.71 certify that no member of the entity's ownership or management is presently applying for any employee position or actively seeking an elected position with the City of Sunny Isles Beach. 18.81 certify that no member of the entity's ownership or management, or staff has a vested interest in any aspect of the City of Sunny Isles Beach. 18.9 In the event that a conflict of interest is identified in the provision of services, I, on behalf of the above named entity, will immediately notify the City of Sunny Isles Beach. 7N M.Af11C ilut)5� this �� day of .2020. ter.. ��,��I�J L�.t le.. ,iLy►v� - tori ly}f!� pvQLJ L or Type Name and TitI���C SwornP and subscribed before me this AL day ofa4c 12020. O Personally Known OR f Produced Identification ;Type of Identification WA tt w -s o DBEs NOTARY PUBLIC STATE OF FLORIDA mea+ +y'� 8tabolllaorldt Iwo► OonrrllMton � ti�+u� �orr� �onl�lonao.Dagtms7 DECEMBER28,2010 �oF %N N Y /S,� EQUAL OPPORTUNITY / AFFIRMATIVE ACTION City of Sunny Isles Beach c'r or suw riyo 18070 Collins Avenue Sunny Isles Beach, FL 33160 Telephone: (305) 947-0606 Fax: (305) 949-3113 EQUAL OPPORTUNITY/AFFIRMATIVE ACTION STATEMENT The contractors and all subcontractors hereby agree to a commitment to the principles and practices of equal opportunity in employment and to comply with the letter and spirit of federal, state, and local laws and regulations prohibiting discrimination based on race, color, religion, national region, sex, age, handicap, marital status, and political affiliation or belief. Signed: a �-- Title:Sl1�T Firm: Address: DECEMBER 28, 2010 i11 111 M��- i j< All " i2 FS�)p1Ny 1$1 n EQUAL. OPPORTUNITY / • �x:x'•ti AFFIRMATIVE ACTION •/ J ",esu P sp fl0y4� City of Sunny Isles Beach Cir' oc SUO 18070 Collins Avenue Sunny Isles Beach, FL 33160 Telephone: (305) 947-0606 Fax: (305) 949-3113 EQUAL OPPORTUNITY/AFFIRMATIVE ACTION STATEMENT The contractors and all subcontractors hereby agree to a commitment to the principles and practices of equal opportunity in employment and to comply with the letter and spirit of federal, state, and local laws and regulations prohibiting discrimination based on race, color, religion, national region, sex, age, handicap, marital status, and political affiliation or belief. Signed: &=-: Title: Firm: Address: OECEMBER28,2010 o' n 9. EQUAL OPPORTUNITY / WxXY',r AFFIRMATIVE ACTION yP FLO sof City of Sunny Isles Beach Crl�OF SU" A��O 18070 Collins Avenue Sunny Isles Beach, FL 33160 Telephone: (305) 947-0606 Fax: (305) 949-3113 EQUAL OPPORTUNITY/AFFIRMATIVE ACTION STATEMENT The contractors and all subcontractors hereby agree to a commitment to the principles and practices of equal opportunity in employment and to comply with the letter and spirit of federal, state, and local laws and regulations prohibiting discrimination based on race, color, religion, national region, sex, age, handicap, marital status, and political affiliation or belief. Signed: Title:!?�T Firm: Address: DECEMBER28,2010 SUNNY lS��. EQUAL. OPPORTUNITY / v x — AFFIRMATIVE ACTION SF 9D�• FLO4�Q y4t City of Sunny Isles Beach c tUN 18070 Collins Avenue Sunny Isles Beach, FL 33160 Telephone: (305) 947-0606 Fax: (305) 949-3113 EQUAL OPPORTUNITY/AFFIRMATIVE ACTION STATEMENT The contractors and all subcontractors hereby agree to a commitment to the principles and practices of equal opportunity in employment and to comply with the letter and spirit of federal, state, and local laws and regulations prohibiting discrimination based on race, color, religion, national region, sex, age, handicap, marital status, and political affiliation or belief. Signed: 4e --- Title: Firm: Address: DECEMBER 28, 2010 i O�S)t4NY 1$4". 0 EQUAL. OPPORTUNITY / U' AFFIRMATIVE ACTION s r f�0P0 y City of Sunny Isles Beach of sUN t''� 18070 Collins Avenue Sunny Isles Beach, FL 33160 Telephone: (305) 947-0606 Fax: (305) 949-3113 EQUAL OPPORTUNITY/AFFIRMATIVE ACTION STATEMENT The contractors and all subcontractors hereby agree to a commitment to the principles and practices of equal opportunity in employment and to comply with the letter and spirit of federal, state, and local laws and regulations prohibiting discrimination based on race, color, religion, national region, sex, age, handicap, marital status, and political affiliation or belief. Signed: Title: _eZes!? r Firm: Address: OECEmsER28,2010 i DISPUTE DISCLOSURE FORM Answer the following questions by placing a "X" after "Yes" or "No". If you answer "Yes", please explain in the space provided, or on a separate sheet attached to this form. 19.1. Has your firm or any of its officers, received a reprimand of any nature or been suspended by the Department of Professional Regulations or any other regulatory agency or professional associations within the last five (5) years? YES NO k' 19.2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a contract or job related to the services your firm provides in the regular course of business within the last five (5) years? / YES NO I✓ 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, or litigation in the past five (5) years that is related to the services your firm provides in the regular course of business? YES NO If yes, state the nature of the request for equitable adjustment, contract claim, litigation, or protest, and state a brief description of the case, the outcome or status of the suit and the monetary amounts of extended contract time involved. I hereby certify that all statements made are true and agree and understand that any misstatement or misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid for the City of Sunny Isles Beach. Flr r, /, / 0 iz t G.�z, DECEMBER 28, 2010 d//0 Al.,v ate Print or Type Name and Title DISPUTE DISCLOSURE _ V •w� Z t City of Sunny Isles Beach 18070 Collins Avenue ,x 99`x.-.:��,,...�_•. Y AQP Sunny Isles Beach, FL 33160 or. soN Telephone: (305) 947-0606 Fax: (305) 949-3113 DISPUTE DISCLOSURE FORM Answer the following questions by placing a "X" after "Yes" or "No". If you answer "Yes", please explain in the space provided, or on a separate sheet attached to this form. 19.1. Has your firm or any of its officers, received a reprimand of any nature or been suspended by the Department of Professional Regulations or any other regulatory agency or professional associations within the last five (5) years? YES NO k' 19.2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a contract or job related to the services your firm provides in the regular course of business within the last five (5) years? / YES NO I✓ 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, or litigation in the past five (5) years that is related to the services your firm provides in the regular course of business? YES NO If yes, state the nature of the request for equitable adjustment, contract claim, litigation, or protest, and state a brief description of the case, the outcome or status of the suit and the monetary amounts of extended contract time involved. I hereby certify that all statements made are true and agree and understand that any misstatement or misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid for the City of Sunny Isles Beach. Flr r, /, / 0 iz t G.�z, DECEMBER 28, 2010 d//0 Al.,v ate Print or Type Name and Title /SFS F'S�NNY DISPUTE DISCLOSURE c + City of Sunny Isles Beach nF-.• r 18070 Collins Avenue Sunny isles Beach, FL 33160 Telephone: (305) 947-0606 Fax: (305) 949-3113 DISPUTE DISCLOSURE FORM Answer the following questions by placing a "X" after "Yes" or "No". If you answer "Yes", please explain in the space provided, or on a separate sheet attached to this form. 19.1. Has your firm or any of its officers, received a reprimand of any nature or been suspended by the Department of Professional Regulations or any other regulatory agency or professional associations within the last five (5) years? YES NO ii 19.2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a contract or job related to the services your firm provides in the regular course of business within the last five (5) years? YES NO k/ 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, or litigation in the past five (5) years that is related to the services your firm provides in the regular course of business? YES NO If yes, state the nature of the request for equitable adjustment, contract claim, litigation, or protest, and state a brief description of the case, the outcome or status of the suit and the monetary amounts of extended contract time involved. I hereby certify that all statements made are true and agree and understand that any misstatement or misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid for the City of Sunny Isles Beach. DECEMBER28,2010 O ® :X- &I ate ,rPont oFType Name and Title Ig�Efe O�.SVNnfY x- DISPUTE DISCLOSURE r x a �# JU City of Sunny Isles Beach 18070 Collins Avenue f LOa�c ., Sunny Isles Beach, FL 33160 c�r1, of sur ° Telephone: (305) 947-0606 Fax: (305) 949-3113 DISPUTE DISCLOSURE FORM Answer the following questions by placing a "X" after "Yes" or "No". If you answer "'Yes", please explain in the space provided, or on a separate sheet attached to this form. 19.1. Has your firm or any of its officers, received a reprimand of any nature or been suspended by the Department of Professional Regulations or any other regulatory agency or professional associations within the last five (5) years? YES NO d" 19.2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a contract or job related to the services your firm provides in the regular course of business within the last five (5) years? YES NO I/ 19.3. Has your firm had against it or flied any requests for equitable adjustment, contract claims, Bid protests, or litigation in the past five (5) years that is related to the services your firm provides in the regular course of business? YES NO If yes, state the nature of the request for equitable adjustment, contract claim, litigation, or protest, and state a brief description of the case, the outcome or status of the suit and the monetary amounts of extended contract time involved. I hereby certify that all statements made are true and agree and understand that any misstatement or misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid for the City of Sunny Isles Beach. 4111r�ecl Si DECEMBER 28, 2010 DZ/—O—/—:I.- e) ate Af 40 *--&-4rint r Type Name and Title ts�FB ¢S�NNY FO.• g 3.e1 DISPUTE DISCLOSURE 0 .r City of Sunny Isles Beach 99' 18070 Collins Avenue s f Flo¢�0 Lt Sunny Isles Beach, FL 33160 C�Tr OF SUK"� Telephone: (305) 947-0606 Fax: (305) 949-3113 DISPUTE DISCLOSURE FORM Answer the following questions by placing a "X" after "Yes" or "No". If you answer "Yes", please explain in the space provided, or on a separate sheet attached to this form. 19.1. Has your firm or any of its officers, received a reprimand of any nature or been suspended by the Department of Professional Regulations or any other regulatory agency or professional associations within the last five (5) years? YES NO k" 19.2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a contract or job related to the services your firm provides in the regular course of business within the last five (5) years? YES NO I✓ 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, or litigation in the past five (5) years that is related to the services your firm provides in the regular course of business? YES NO If yes, state the nature of the request for equitable adjustment, contract claim, litigation, or protest, and state a brief description of the case, the outcome or status of the suit and the monetary amounts of extended contract time involved. I hereby certify that all statements made are true and agree and understand that any misstatement or misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid for the City of Sunny Isles Beach. DECEMBER28,2010 DS L11-0 Z-2�'e> ate ZR?ed Sfgiii� Print or Type Name and Title .yNNY /S< u� is �_', ' CONTRACTOR ANTI -BOYCOTT CERTIFICATION A/ • f L.O K,O [PURSUANT TO FLORIDA STATUTE § 215.4725] I, , on behalf of4f mxv &r3 Print Name Company Name certifies that LX ,¢L J6N �i 4r 4W- does not: Company Name 1. Participate in a boycott of Israel; and 2. Is not on the Scrutinized Companies that Boycott Israel list; and 3. Is not on the Scrutinized Companies with Activities in Sudan List; and 4. Is not on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List; and 5. Has not engaged in business operations in Cuba or Syria. SiWture Title /_9 0 A0 Date a , n • !•- CONTRACTOR ANTI -BOYCOTT CERTIFICATION Sf t O R`O h4! °f'°" `�° [PURSUANT TO FLORIDA STATUTE § 215.47251 I, , on behalf of U110/ i TLl� Print Name Company Name certifies that 4 LXA1& a .00iii,/ 4W- does not: Company Name 1. Participate in a boycott of Israel; and 2. Is not on the Scrutinized Companies that Boycott Israel list; and 3. Is not on the Scrutinized Companies with Activities in Sudan List; and 4. Is not on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List; and 5. Has not engaged in business operations in Cuba or Syria. Sigtf�tore Title — 12.6 An ZZ�42- Date o� NAY I stE�e 4 A v CONTRACTOR ANTI -BOYCOTT CERTIFICATION 9•fl�p'`O R4 [PURSUANT TO FLORIDA STATUTE § 215.4725] I, on behalf of Print Name Company Name certifies that �fn/ ,4Z Jso y` i,% 4W- does not: Company Name 1. Participate in a boycott of Israel; and 2. Is not on the Scrutinized Companies that Boycott Israel list; and 3. Is not on the Scrutinized Companies with Activities in Sudan List; and 4. Is not on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List; and 5. Has not engaged in business operations in Cuba or Syria. Sigff�ture /��%ffg�� Title /_9 9 At,> Date o, SUNNY s<fJe CONTRACTOR ANTI -BOYCOTT CERTIFICATION av: fiti-•-: T C'I, or sU++ *OO [PURSUANT TO FLORIDA STATUTE § 215.47251 I, —6w ' on behalf of alR"d�Af3L�� TLS Print Name Company Name certifies thatn1 does not: Company Name 1. Participate in a boycott of Israel; and 2. Is not on the Scrutinized Companies that Boycott Israel list; and 3. Is not on the Scrutinized Companies with Activities in Sudan List; and 4. Is not on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List; and 5. Has not engaged in business operations in Cuba or Syria. Sigff�ture Title /-9.0 Ao zz:�4_2_ Date o`� NNY IsEJs y,t CONTRACTOR ANTI -BOYCOTT CERTIFICATION [PURSUANT TO FLORIDA STATUTE § 215.47251 I, 4W 1 on behalf of LIWIAl *rteLd9^)M t4 Ll� Print Name Company Name certifies that 6a 4�-Ojwy�i14f — does not: Company Name 1. Participate in a boycott of Israel; and 2. Is not on the Scrutinized Companies that Boycott Israel list; and 3. Is not on the Scrutinized Companies with Activities in Sudan List; and 4. Is not on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List; and 5. Has not engaged in business operations in Cuba or Syria. Sigff�ture Title /_9 9 lltc� AC53 Date S, to NY rS�F 9 PUBLIC ENTITY CRIMES City of Sunny Isles Beach r 18070 Collins Avenue %w9f. FLoa`c 5` Sunny Isles Beach, FL 33160 or. su>a " Telephone: (305) 947-0606 Fax: (305) 949-3113 SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(x) 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. 11.1. This sworn statement is submitted to City of Sunny Isles Beach by 1z, for �������s ��s�G//<✓�r 4 L c ' print name of enuty-submitung swum s a emen and (if applicable) its Federal Employer Identification number (FEIN) is O2'.3,0Z 6 ,qz® . (if the entity had no FEIN, include the Social Security Number of the individual signing this statement: ) 0 r sworn 11.2. 1 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. 11.3. 1 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. 11.4. 1 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 DECEMBER 28, 2010 market value under an arm's length agreement, shall be a prime facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. 11.5. 1 understand that a "person" as defined in Para. 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding Contract and which Bids or applies to Bid on Contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "persons" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of any entity. 11.6. Based on information and belief, the statement which I have marked below is true in relation to the entity / submitting this sworn statement. (Indicate which statement applies.) V Neither the entitysubmitting this sworn statement, nor an of it's officers, directors, executives, partners, 9 Y shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (Attach a copy of the final order.) I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. By: A, VZv, f , Vs. (Sig ture) _ (Printed Na e) (Title) Sworn to an ubscribed before me this _ day of &2b t2S`T 20 00 by VQEEF4d%-/ (AFFIX NOTARY STAMP HERE) •"" 0. Signature: ekft of Flaft �N ��A►tenona�eeoeroar�o29 °' Commtatta► No. 60 91018? Personally Known OR Produced Identification �LDR)ad �1t2� L,tI F/VS�r market value under an arm's length agreement, shall be a prime facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. 11.5. I understand that a "person" as defined in Para. 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding Contract and which Bids or applies to Bid on Contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "persons" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of any entity. 11.6. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. (Indicate which statement applies.) Neither the entity submitting this sworn statement, nor any of it's officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (Attach a copy of the final order.) I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. By: (Title) Sworn to aqOubscribed before me this J_ day of/r,Hj�t i9S ] '20. , by (AFFIX NOTARY STAMP HERE) ftwm 40-0.101"M � Signature: MYftM M SON06 Q 0/ ConxMplotl Na ea 910187 Personally Known OR Produced Identification z�24 1? )104,kl--A/ U@25 Ll L AUS f.� AOS SVN h1 Y 1StF�@�" PUBLIC ENTITY CRIMES 4 City of Sunny Isles Beach r 18070 Collins Avenue yp� FLoPQy`r Sunny Isles Beach, FL 33160 `r" or :u" "" 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. 11.1. This sworn statement is submitted to City of Sunny Isles Beach by 1zr for-��,� ams srJ�`l L% /�✓�, G Z e iprint name oi enury-submaung sworn s a emen whose business address is: and (if applicable) its Federal Employer Identification number (FEIN) is_p l ".3� (If the entity had no FEIN, include the Social Security Number of the individual signing this sworn statement: ) 11.2. 1 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. 11.3. 1 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. 11.4. 1 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 DECEMSER28,2010 market value under an arm's length agreement, shall be a prime facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. 11.5. I understand that a "person" as defined in Para. 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding Contract and which Bids or applies to Bid on Contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "persons" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of any entity. 11.6. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. (Indicate which statement applies.) y/ Neither the entity submitting this sworn statement, nor any of it's officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (Attach a copy of the final order.) I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. By: (Title) Sworn to a /� ubscribed before me this 1 day of f -20 t9s7r , 20,DD, by 4RQ1� FAEFiamlz (AFFIX NOTARY STAMP HERE) 05 OrdwN a rMwo Signature: Personally Known OR Produced Identification Fin oyd ksaawjZ L„t j r --us/= A.�� �VNNY is, FS@� z PUBLIC ENTITY CRIMES U City of Sunny Isles Beach 18070 Collins Avenue yFc 9'' F�oa�Ooy�r Sunny Isles Beach, FL 33160 �Ty oo fuN A,l 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. This sworn statement is submitted to City of Sunny Isles R.ti6h,. A _ ky and (if applicable) its Federal Employer Identification number (FEIN) is Y2 "_ 3.7-6 9 / �0 (if the entity had no FEIN, include the Social Security Number of the individual signing this statement: ) El sworn 11.2. 1 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. 11.3. 1 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. 11.4. 1 understand that an "affiliate" as defined in Para. 287.133(1)(a), Florida Statutes, means: a.) predecessor or successor of a person convjcted 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 DECEMBER28,2010 market value under an arm's length agreement, shall be a prime facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. 11.5. I understand that a "person" as defined in Para. 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding Contract and which Bids or applies to Bid on Contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "persons" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of any entity. 11.6. Based on information and belief, the statement which I have marked below is true in relation to the entity / submitting this sworn statement. (Indicate which statement applies.) Neither the entity submitting this sworn statement, nor any of it's officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (Attach a copy of the final order.) I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. By: (Sig (Printed (Title) nn Sworn to ar4Oubscribed before me this_ day of 20_a by (AFFIX NOTARY STAMP HERE) Ed�vedQ' Signature: >�aosatt�IorWa .-- '� �Mi►Con�ronEkptrosoeun4l�23 °" Comn�gfon Mo. GO 910th! Personally Known OR Produced Identification Y_1_n 07�,��U�:�25 � SVNNY'S�FB PUBLIC ENTITY CRIMES •� `?�� M City of Sunny Isles Beach 18070 Collins Avenue Sunny Isles Beach, FL 33160 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. 11.1. This sworn statement is submitted to City of Sunny Isles Beach by 1z, for dl m r_�w APC_ �..t �1s41 �Nry L e Tm name o en m ung swom s a emen and (if applicable) its Federal Employer Identification number (FEIN) is_Y2 - 3o?- 6 ? ! 1—® (If the entity had no FEIN, include the Social Security Number of the individual signing this statement: ) J sworn 11.2. 1 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. 11.3. 1 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. 11.4. 1 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 OECEMBER28,2010 Sa14NY 1s<F Off, w z PUBLIC ENTITY CRIMES • ' y • City of Sunny Isles Beach 18070 Collins Avenue rLoA`005�* Sunny Isles Beach, FL 33160 o. SUN " 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. 11.1. This sworn statement is submitted to City of Sunny -Isles Beach by 1z, ......-------. -------_ _.._ ----- for —,forui ���,�!���i®�a�s n%s�OG//�►/�y L c pnn name OT enuPfauDmitung swom statemenq and (if applicable) its Federal Employer Identification number (FEIN) is -,$2 3.Z 6 9 ! 7--® (If the entity had no FEIN, include the Social Security Number of the individual signing this statement: ) sworn 11.2. 1 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. 11.3. 1 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. 11.4. 1 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 DECEMBER 28,2010 market value under an arm's length agreement, shall be a prime facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. 11.5. I understand that a "person" as defined in Para. 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding Contract and which Bids or applies to Bid on Contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "persons" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of any entity. 11.6. Based on information and belief, the statement which I have marked below is true in relation to the entity / submitting this sworn statement. (Indicate which statement applies.) Neither the entity submitting this sworn statement, nor any of it's officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (Attach a copy of the final order.) I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. By: Sworn to arlOubscribed before me this JJ-_ day of f-Hit1 i9S�` , 20, by �_ln%(di2Y� lE,�J (AFFIX NOTARY STAMP HERE) ►�"' i1:AwddQFisenilil Signature: '� BMyComrn�elon6�p1ros0slro4/2o29 w �Ilpf011 N0. Citi 910187 T� Personally Known OR Produced Identification.Fin in i9 1 X6 k,--aLLzr, Llzr--/uS,�F