HomeMy WebLinkAboutHardcore Shotcrete Skateparks Inc.
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NON-COLLUSION AFFIDAVIT
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
The undersigned being first duly sworn as provided by law, deposes, and says:
1.1. 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 City, in
any consideration which may give to and any action it may take with respect to this proposal.
1.2. The undersigned is authorized to make this Affidavit on behalf of,
American Ramp Company dba. Hardcore Skateparks (Name of Corporation, Partnership,
Individual, etc.), a corporation duly organized and existing under the laws of the State of
Missouri of which he is President (Sole Owner,
Partner, President, etc.)
1.3. Neither the undersigned nor any person, firm, or corporation named in above
Paragraph 1.2, nor anyone else to the knowledge of the undersigned, have themselves
solicited or employed anyone else to solicit favorable action for this proposal 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.
1.4. This proposal is genuine and not collusive or a sham; the person, firm or corporation
named above in Paragraph 1.2 has not colluded, conspired, connived or agreed directly or
indirectly with any Proposer or person, firm or corporation, to put in a sham proposal, or that
such person, firm or corporation, shall refrain from Proposing, 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 proposal or proposals of any
other Proposer; and all statements contained in the proposal or proposals described above are
true; and further; neither the undersigned, nor the person, firm or corporation named above in
Paragraph 1.2, has directly or indirectly submitted said proposal or the contents thereof, or
divulged information or data relative thereto, to any association or to any member or agent
thereof.
Nathan Bemo
AFFIANT'S NAME
President
AFFIANT'S TITLE
19
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. ..
The foregoing Affidavit was acknowledged before me this~ day of Nov. ,2009, by
Nathan Bema as President of
-'
Hardcore Shotcrete Skateparks ,a Missouri corporation, on behalf of said corporation and
limited partnership. He/She personally appeared before me and is personally known to me.
{ NOTaRIAL SEAL }
Notary: wJ.L-o- ~ .~
Print Name: LV, ti, tJ...... f-\..:.....Ls~ ,,~~~ t.y
Notary Public, State oflOOttd:a Mi~souri
My Commission Expires: t()urz.J..., b "Lot)
W1WAM H. ISENBERGEft
Notary Public - Notary Seal
State of Missouri
Commissioned for Jasper County
My Commission Expires: March 30, 2013
CommissIon Number. 09976702
20
f' .,
FLORIDA DEPARTMENT OF STATE
Division of Corporations
January 18, 2007
BILL ISENBERGER
601 MCKINLEY AVE
JOPLIN, MO 64801
Qualification documents for AMERICAN RAMP COMPANY were filed on
January 16, 2007 and assigned document number F07000000276. Please refer to this
number whenever corresponding with this office.
Your corporation is now qualified and authorized to transact business in Florida as of
the file date.
The certification you requested is enclosed.
A corporation annual report/uniform business report will be due this office between
January 1 and May 1 of the year following the calendar year of the file date. A Federal
Employer Identification (FEI) number will be required before this report can be filed. If
you do not already have an FEI number, please apply NOW with the Internal Revenue
by calling 1-800-829-3676 and requesting form SS-4.
Please be aware if the corporate address changes, it is the responsibility of the
corporation to notify this office.
Should you have any questions regarding this matter, please contact this office at the
address given below.
Cynthia Blalock
Document Specialist
New Filing Section
Division of Corporations
Letter Number: 207 A00004019
P.O. BOX 6327 -Tallahassee, Florida 32314
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I certify from the records of this office that AMERICAN RAMP COMPANY, is a
corporation organized under the laws of Missouri, authorized to transact business
in the State of Florida, qualified on January 16, 2007.
The document number of this corporation is F07000000276.
I further certify that said corporation has paid all fees due this office through
December 31,2007, and its status is active.
I further certify that said corporation has not filed a Certificate of Withdrawal.
Given under my hand and the
Great Seal of the State of Florida
at Tallahassee, the Capitol, this the
Eighteenth day of January, 2007
CR2E022 (01-07)
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SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a)
FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY
PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
1. This sworn statement is submitted
to City of Sunny Isles Beach, Florida
by American Ramp Company dba. Hardcore Shotcrete Skateparks
for City of Sunny Isles Beach, Flordia
whose business address is
18070 Collins Ave., 1st Floor Meeting Room
Sunny Isles Beach, Florida 33160
and (if applicable) its Federal Employer Identification Number (FEIN)
35-2353308
(If the entity had no FEIN, include the Social Security Number of the individual signing
this sworn statement:
2. I understand that a "public entity crime" as defined in Paragraph 287.133(l)(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 of 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 or of the United States and involving
antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material
misrepresentation.
3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(l)(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 trial court of record relating to
charges brought by indictment or information after July 1, 1989, as a result of a jury
verdict, nonjury trial, or entry of a plea of guilty or nolo contenders.
4. I understand that an "affiliate" as defined in Paragraph 287.133(l)(a), Florida Statutes,
means:
a. A predecessor or successor of a person convicted of a public entity crime; or
b. An 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 come. The term "affiliate"
includes those officers, directors, executives, 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 market
value under an arm's length agreement, shall be a prima facie case that one person
controls another person. A person who knowingly enters into a joint venture with a
18
person who has been convicted of a public entity crime in Florida during the
preceding 36 months shall be considered an affiliate.
5. I understand that a "person" as defmed in Paragraph 287.133(I)(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
"person" includes those officers, directors, executives, partners, shareholders, employees,
members, and agents who are active in management of any entity.
6. Based on information and belief, the statement which I have marked below is true in a
relation to the entity submitting this sworn statement. (Please indicate which one (1) of
the following three (3) statements is applicable.)
~ (1) Neither the entity submitting this sworn statement, nor any of its officers,
directors, executives, partners, shareholders, employees, members, or agents who are active
in the management of the entity, or any affiliate of the entity has been charged with and
convicted of a public entity crime within the past 36 months.
_(2) 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 any affiliate of the entity has been charged with and
convicted of a public entity crime within the past 36 months.
_(3) 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 agents who are active in management of the entity, or
any affiliate of the entity has been charged with and convicted of a public entity crime
within the past 36 months. However, there has been a subsequent proceeding before a
Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final
Order 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. (Attached is a copy of
the fmal order.)
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE
CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN
PARAGRAPH 1 (ONE) ABOVE IS FOR THE PUBLIC ENTITY ONLY AND, THAT
THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN
WHICH IT IS FILED AND FOR THE PERIOD OF THE CONTRACf ENfERED INTO,
WHICHEVER PERIOD IS LONGER. I ALSO UNDERSTAND THAT I AM REQUIRED
TO INFORM THE PUBLIC ENTITY PRIOR TO ENfERING INTO A CONTRACT IN
EXCESS F THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017,
FLOR STATUTES FOR THE CATEGORY lWO OF ANY CHANGE IN THE
N CONTAINED IN THIS FORM.
Nathan Bema, President
(Printed or Typed Legal Name of Affiant)
17
Missouri
STATEOF~ )
Jasper )S8.
COUNTYOF~)
The foregoing Form was acknowledged before me this 24th day of Nov. ,2009, by
Nathan Bema as President of
Hardcore Shotcrete Skateparks ,a Missouri co~oration, on behalf of said corporation and
limited partnership. He/She personauy appeared before me and is personally known to me.
{ NOTARY SEAL }
W1WAM H.ISENBERGEft
NotarY Public - Notary Seal
State of Missouri
Commissioned for Jasper County
My ComlTlisslon Expires: March 3D, 2013
CO' ,_ ...'~slon Number: 09976702
Notary:w~ 4~
Print Name i.,J,ILu/"" rl .:LS<t:"~<t: l<ta.,.l
Notary Public, State of ~ Missouri
My Commission Expires: rounh "1p 10'3
18
,..
January 18, 2007
BILL ISENBERGER
601 MCKINLEY AVE
JOPLIN, MO 64801
Qualification documents for AMERICAN RAMP COMPANY were filed on
January 16, 2007 and assigned document number F07000000276. Please refer to this
number whenever corresponding with this office.
Your corporation is now qualified and authorized to transact business in Florida as of
the file date.
The certification you requested is enclosed.
A corporation annual report/uniform business report will be due this office between
January 1 and May 1 of the year following the calendar year of the file date. A Federal
Employer Identification (FEI) number will be required before this report can be filed. If
you do not already have an FEI number, please apply NOW with the Internal Revenue
by calling 1-800-829-3676 and requesting form SS-4.
Please be aware if the corporate address changes, it is the responsibility of the
corporation to notify this office.
Should you have any questions regarding this matter, please contact this office at the
address given below.
Cynthia Blalock
Document Specialist
New Filing Section
Division of Corporations
Letter Number: 207 A00004019
P.O. BOX 6327 -Tallahassee, Florida 32314
..
;1
.
~-!
NON. COLLUSION AFFIDAVIT
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
The undersigned being first duly sworn as provided by law, deposes, and says:
1.1. 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 City, in
any consideration which may give to and any action it may take with respect to this proposal.
1.2. The undersigned is authorized to make this Affidavit on behalf of,
American Ramp Company dba. Hardcore Skateparks (Name of Corporation, Partnership,
Individual, etc.), a corporation duly organized and existing under the laws of the State of
Missouri of which he is President (Sole Owner,
Partner, President, etc.)
1.3. Neither the undersigned nor any person, firm, or corporation named in above
Paragraph 1.2, nor anyone else to the knowledge of the undersigned, have themselves
solicited or employed anyone else to solicit favorable action for this proposal 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.
1.4. This proposal is genuine and not collusive or a sham; the person, firm or corporation
named above in Paragraph 1.2 has not colluded, conspired, connived or agreed directly or
indirectly with any Proposer or person, firm or corporation, to put in a sham proposal, or that
such person, firm or corporation, shall refrain from Proposing, 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 proposal or proposals of any
other Proposer; and all statements contained in the proposal or proposals described above are
true; and further; neither the undersigned, nor the person, firm or corporation named above in
Paragraph 1.2, has directly or indirectly submitted said proposal or the contents thereof, or
divulged information or data relative thereto, to any association or to any member or agent
thereof.
Nathan Bemo
AFFIANT'S NAME
President
AFFIANT'S TITLE
19
,~-Ii
The foregoing Affidavit was acknowledged before me this~ day of Nov. ,2009, by
Nathan Bema as President of
-'
Hardcore Shotcrete Skateparks ,a Missouri corporation, on behalf of said corporation and
limited partnership. He/She personally appeared before me and is personally known to me.
{ NOTaRIAL SEAL}
WILLIAM H. ISENBERGE~
Notary Public - Notary Seal
State of Missouri
Commissioned for Jasper County
My Commission Expires: March 30,2013
Commission l~u:nber: 09976702
Notary: wJ.L-o- ~ ~
Print Name: Will, (,'..... H..:.J..$e ,,~~~ t.Y
Notary Public, State ofR~ Mi~souri .
My Commission Expires: t()c/rz.J...,':t> "LQt")
20
-.
SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a)
FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY
PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
1. This sworn statement is submitted
to City of Sunny Isles Beach, Florida
by American Ramp Company dba. Hardcore Shotcrete Skateparks
for City of Sunny Isles Beach, Flordia
whose business address is
18070 Collins Ave., 1st Floor Meeting Room
Sunny Isles Beach, Florida 33160
and (if applicable) its Federal Employer Identification Number (FEIN)
35-2353308
(If the entity had no FEIN, include the Social Security Number of the individual signing
this sworn statement:
2. I understand that a "public entity crime" as defined in Paragraph 287.133(l)(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 of the United States, including, but not limited
to, any bid or contract for goods or seIVices to be provided to any public entity or an
agency or political subdivision of any other state or of the United States and involving
antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material
misrepresentation.
3. I understand that "convicted" or "conviction" as defined in Paragraph 287. 133(l)(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 trial court of record relating to
charges brought by indictment or information after July 1, 1989, as a result of a jury
verdict, nonjury trial, or entry of a plea of guilty or nolo contenders.
4. I understand that an "affiliate" as defined in Paragraph 287.133(l)(a), Florida Statutes,
means:
a. A predecessor or successor of a person convicted of a public entity crime; or
b. An 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 come. The term "affiliate"
includes those officers, directors, executives, 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 market
value under an arm's length agreement, shall be a prima facie case that one person
controls another person. A person who knowingly enters into a joint venture with a
16
person who has been convicted of a public entity CrIme in Florida during the
preceding 36 months shall be considered an affiliate.
5. I understand that a "person" as defined in Paragraph 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
"person" includes those officers, directors, executives, partners, shareholders, employees,
members, and agents who are active in management of any entity.
6. Based on information and belief, the statement which I have marked below is true in a
relation to the entity submitting this sworn statement. (Please indicate which one (1) of
the following three (3) statements is applicable.)
~ (I) Neither the entity submitting this sworn statement, nor any of its officers,
directors, executives, partners, shareholders, employees, members, or agents who are active
in the management of the entity, or any affiliate of the entity has been charged with and
convicted of a public entity crime within the past 36 months.
_(2) 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 any affiliate of the entity has been charged with and
convicted of a public entity crime within the past 36 months.
_(3) 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 agents who are active in management of the entity, or
any affiliate of the entity has been charged with and convicted of a public entity crime
within the past 36 months. However, there has been a subsequent proceeding before a
Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final
Order 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. (Attached is 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 1 (ONE) ABOVE IS FOR THE PUBLIC ENTITY ONLY AND, THAT
THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN
WHICH IT IS FILED AND FOR THE PERIOD OF THE CONTRACT ENTERED INTO,
WHICHEVER PERIOD IS LONGER. I ALSO UNDERSTAND THAT I AM REQUIRED
TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN
EXCESS F THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017,
FLOR STATUTES FOR THE CATEGORY TWO OF ANY CHANGE IN THE
I N CONTAINED IN THIS FORM.
Nathan Bema, President
(Printed or Typed Legal Name of Affiant)
17
Missouri
STATEOF~ )
Jasper )ss.
COUNTY OF~)
The foregoing Form was acknowledged before me this 24th day of Nov. ,2009, by
Nathan Bema ,as President of
Hardcore Shotcrete Skateparks ,a Missouri corporation, on behalf of said corporation and
limited partnership. He/She personally appeared before me and is personally known to me.
{ NOTARY SEAL}
Notary:w~"", 4~
Print Name 0. ILl U,..." rl .:LS<C:fJ!:7.e ~a'/
Notary Public, State of ~ Missouri
My Commission Expires: t'(){/n..h 1,0 1.0/3
WlLUAM H.ISENBERGER
Notary Public - Notary Seal
State of Missouri
Commissioned fOI Jasper County
My Commission Expires: March 30, 2013
Co' 'sslon Number: 09976702
18