1990 Buick Century for Growth Management
1~~~1
LEASE AGREEMENT
GMAC
FINANCIAL SERVICES
LESSEE (and CO-LESSEE, if any)
Name and Address (include County and Zip Code)
COUNTY OF MOROE fLADlHG DEPT.)
5825 JR. COLLEGE RD. J WING III
KEY WEST. PL. 33040 KODO! co.
LESSOR: (Dealer Name and Address)
BOB CHANGO, llie.
3500 N. ROOSEVELT BLVD.
DY WEST. FL. 33040
Lessor intends to assign this Lease Agreement (including the payments due under it) to General Motors Acceptance Corporation (GMAC). The word
;'Lessor" refers to the Lessor named above and, after assignment, GMAC or any later assignee. The word "Lease" refers to this Lease Agreement.
By signing this Lease, you (the Lessee and any Co-Lessee) and Lessor agree to your lease of the vehicle described below. You agree to all the terms and
conditions on the front and back of this Lease.
Year Make & Model
HU1Gl(
1990 CENTURY
Body Type
Vehicle Identification Number
4 DOOR
Primary Use for Which Leased
o Personal, Family or Household
~ Business or Agricultural
C7 Power :'7 Power Sun ~7Tilt
W,ndows Seats Roof Wheel
Including: iU} Automatic
Trans.
[J Cruise
Control
IG4AH54N6L6454637
LJAir
Condo
o Stereo
Tape
OTHER:
INSURANCE
A. VEHICLE INSURANCE. During this Lease, you must provide and
pay for the following insurance covering both you and Lessor:
(1) Public Liability Insurance that eithef (a) covers up to $50,000 for
property damage, $100,000 for bOdily injuries to anyone person,
and $300~O for bodily injuries for anyone accident, or (b) has a
combined single limit of $300,000 for bodily injuries and property
damage for anyone accident; and
(2) Physical Damage Insurance covering loss or damage to the vehicle.
with deductibles of no more than $500 for collision and upset loss
and $250 for comprehensive fire and theft loss.
The policy of Public Liability Insurance must show GMAC as an additional
Insured. The polICY of Physical Damage Insurance must show GMAC as
loss payee . You may choose to get the required coverages yourself or
through any person. The policies must be written by an insurance company
acceptable to Lessor and GMAC. You agree to provide proof of insurance
to Lessor and GMAC upon request. No other types of insurance are
required by Lessor.
INSURANCE NOTICE:
THE VALID AND COLLECTIBLE LIABILITY INSURANCE OR PER-
SONAL INJURY PROTECTION INSURANCE PROVIDING COVERAGE
FOR THE LESSOR OF A MOTOR VEHICLE FOR RENT OR LEASE
SHALL BE PRIMARY UNLESS OTHERWISE STATED IN BOLD TYPE
ON THE FACE OF THE RENTAL OR LEASE AGREEMENT. SUCH
INSURANCE SHALL BE PRIMARY FOR THE LIMITS OF LIABILITY
AND PERSONAL INJURY PROTECTION COVERAGE AS REQUIRED
BY ~9 324.021 (7) AND 627.736.
YOU AGREE THAT YOUR OWN LIABILITY AND PERSONAL INJURY
PROTECTION INSURANCE WILL PROVIDE PRIMARY INSURANCE
COVERAGE UP TO ITS FULL POLICY LIMITS UNDER THE
AGREEMENT.
(NAME OF LESSEE'S INSURANCE COMPANY)
B. OPTIONAL LIFE AND DISABILITY INSURANCE. Lessor does not
require life and/or disability insurance covering your lease payment
obligations. If you sign below, Lessor will try to get the coverage(s)
checked for the term of the Lease. The premium cost is shown below
and will be included in the Base Monthly Payment (Item 2(a)). The
terms and conditions of the coverage(s) will be described in the notice
or insurance agreement given to you when you sign this Lease. See
Item 24 on the back of the Lease for additional obligations and informa-
tion about this insurance.
Insurer Name
Add ress
to-,-' ;:~ ( }:,,<:, ~:"~':Y_': ~.:~~,'~
'j' :~;;~~>:..; :>~~~:.~; ,:}i /, ~~_ ~':'; ~" ,~:
o Life Insurance (Lessee 0 Co-Lessee 0 Both 0)
Premium $
Coverage undEt! this policy is limited to $';",,~") "';P'J'
o Disability, Accident and Health Insurance (Lessee Only)
Premium $_:;{:i...;~2i~~.."
Coverage under this pOlicy is limited to a maximum monthly amount of
$ ",. ,. ,t l
al.A<~ .
Lessee's Signature J'.
~, .;.~,<",'i L,
. <.
Age~
Age~
!,.
Co-lessee's Signature '. ,,~.
,t".. ' .
Power
Steering
1. PAYMENT DUE AT LEASE SIGNING. You agree to pay the following
amounts when you sign this Lease:
(a) Capitalized Cost Reduction (cash) . . . . 1 (a) $
(b) Net Trade-In Allowance. .1 (b) $
(c) First Monthly Payment in Advance 1 (c) $
Cd) Refundable Security Deposit . . . . . . . .1 Cd) $
(e) Title Fee, . . . . . . . . . . . . . . . . . . . . . . . . . 1 (e) $
(f) Registration Fee. . . . . . . . . . . . . .. ... 1 (f) $
(g) License Fee. . . .1 (g) $
(h) Sales Tax . . . . . . 1 (h) $
(i) Ex c I se Tax . . . . . . . 1 (i) $
U) Rental/Use Tax. . . . . . . . . . . . .. .... 1 (j) $
(k) Personal Property Tax . . . . . . 1 (k) $
(I) Other (describe) IfttIM . . 1 (I) $
(m) Other Cdescribe)DalaMft ~m) $
(n) TOTAL PAYMENT DUE
AT LEASE SIGNING. . . . . . . . . . . . . . .1(n) $
2. MONTHLY PAYMENT.
(a) Base Monthly Payment . . . . . . . . . . . . . 2(a) $
(b) Rental/Use Tax. . . . . . . . . . . . . . . . . . . .2(b) $
(c) Personal Property Tax . . . . . . . .. ... 2(c) $
(d) Other (describe) . .2(d) $
(e) Other (describe) . .2(e) $
(1) TOTAL MONTHLY PAyMENT...... .2(t) $
>>
3. TERM. The term of this Lease is
months.
KIA
>>/A
298.80
RIA
B/A
K/A
81.8S
RIA
KIA
MIA
RIA
2.00
21.50
404.15
298.80
N/A
H/A
BIA
B/A
29&.80
4. PAYMENT SCHEDULE. You agree to pay 36 Monthly
Payments of $2".. . Your first Monthly Payment is due when
you sign this Lease. Your remaining 3S Monthly Payments
are due on the day of each month, beginning with the
month of , 19_.
5. TOTAL OF MONTHLY PAYMENTS . . . . . . 5
$ 10756.80
6. TOTAL OF OTHER CHARGES PAYABLE TO LESSOR (describe).
(a) .'. 6(a) $ II A
(b) 6(b) $ 141 A
". RIA
(c) TOTAL OF OTHER CHARGES. . . . . . .8(.) '.
7. TOTAL ESTIMATED FEES AND TAXES PAYABLE DURING LEASE
TERM.
(a) Title Fees. . . . . . . . . . . . . . . . . . . . . . . . . 7(a) $
(b) Registration Fees. . . . . . . . . . . . . . . . . .7{b) $
(c) License Fees. . . . . . . . . . . . . . . . . . . . . . 7(c) $ 24.5..55
(d) Sa. les. T. ax. e. s . . . . . . . . . . .. ... .... . . . . . ......:.'...'.....:...'..:'...'.'.:'.'.'.'.........;...".'.I..',.......'.~.'... ".,.'.
. . . ; . ; .~, . '.. ." l7=p;~~_:'l~\; .
(e) EXCise Taxes. . .. . . . . .. . . . . . . . . . . .. .',
(f) Rental/Use Taxes. . . . . . . . . . . . . . . . . . 7 (f) $. .-, A
(9) Personal Property Taxes. . . . . . . . . . . .1(g) $ .B/A
(h) Other (describe).' .' . . 7(h) $: "'21.. 50
(i) TOTAL ESTIMATED FEES .267 OS
AN 0 TAX E S. . . . . . . . . . . . . . . . . . . . . . . 7(1) S . .
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"...-. wrrtten consent,
(e) alter. mark. or install equipment in the vehicle without Lessor's written
consent
15. MAINTENANCE, REPAIRS AND OPERATING EXPENSES. You agree
to maintain and repair the vehicle to keep it in good working order and
condition. You agree to pay for or cover all maintenance, repair, and oper-
ating expenses. You also agree.to servfce the vehfcte as the manufac-
turer recommends in the Owner's Manual and Maintenance Schedule
folder that comes with the vehicle and as the manufacturer requests in
any recall campaign.
16. WARRANTIES. The only express warranty to which the vehicle is
subject is any standard manufacturer's express warranty Lessor agrees
to aflow you to receive the benefits of any manufacturer's express war-
ranty that comes with the vehicle. You wilt also have an extended war-
ranty or service contract if you arranged for one with this Lease.
I n a dispute about the manufacturer's warran~ you agree to keep mak-
ing Monthly Payments to Lessor. You may not withhold payments from
Lessor unless permitted by law.
V..... understand that lessor4fs not offering any express or implied war-
ranties and that Lessor offers no implied warranties of merchantability,
suitability, or fitness for a particular purpose covering the vehicle.
17. OFFICIAL FEES AND TAXES. You agree to pay all fees and charges
for titling, registering, licensing, testing, and inspecting the vehicle that
any government authority requires during the term of this Lease. You
agree to pay all taxes related to the Lease or the vehicle that are levied on
you, the vehicle. or Lessor, except for taxes on Lessor's net income. The
taxes you must pay will be included in the Payment Due at Lease Signing
or your Monthly Payment or separately billed to you by Lessor. Lessor
rnay change your Monthly Payment for increases or decreases in taxes.
18. FINES, LIENS, AND ENCUMBRANCES. You agree to keep the vehi-
cle free of all fines, liens, and encumbrances. If you do not promptly pay
any fines or remove any liens or encumbrances, Lessor may do so. You
will owe Lessor any amounts Lessor pays to do so.
19. RETURN OF VEHICLE. If you do not buy the vehicle at the sched-
uled end of the Lease (Item 10) you agree to return the vehicle at the end
of the Lease to the Dealer's address shown on this Lease or to any rea-
sonable address Lessor gives you. The vehicle must be in good working
order and condition. Vou agree to pay the cost of all repairs needed
because of excessive wear and use to put the vehicle in good working
order and condition.
20. EXCESSIVE WEAR AND USE. "Excessive wear and use" includes,
8Plon~1 other things (a) glass that is damaged or broken or that you have
tinted; (b) damaged body. fenders. metal work, lights. trim or paint (c)
rrl!Sslng equipment that was in the vehicle when delivered and has not
bpen replaced with equipment of equal quality and design; Cd) missing
wheel covers, jaCk or wheel wrench; (e) missing wheels or tires (includ-
ing spare) or unsafe wheels or tires (snow tires are not acceptable); (f)
arty tire with less than 1/8 Inch of tread remaining at the shallowest point;
(q 'j torn, damaged. or stained dash. floor covers, seats, headliners, uphol-
sterv Interior work or trunkliners; (h) darnage or other condition that makes
tt1P\'ehlcle unsafe or unlawful to operate; (i) any mechanical damage or
other condition that causes the vehicle to operate in a nOisy. rough. or
jrnproper f11anner, and (j) any other damage whether or not covered by
I ;V::'u ranee,
21. SCHEDULED TERMINATION. If you return the vehicle at the sched-
uled end of the Lease (Item 19), and if you have not broken any of your
aqreements in the Lease, the only amounts you wilf owe Lessor will be
any excess mileage charge (Item 9) and the cost of any repairs needed
bAcause of excessive wear and use (Item 20).
22. DEFAULT.
(8') You Will be In default If any of the following occurs:
(1) You do not nlake a payment when due
:'~)i A proceeding in bankruptcy, receivership, or insolvency is started
by \/ou or against you or your property.
-'f'l"'<lfle..(;,~ lfftfioiJforeach of the-peace, at reasonable- times and"p"iaces:
in a reasonable manner and in accordance with applicable law. If you
are in default and if the law permits, you agree that Lessor or its agents
may enter your property or the property where the vehicle is stored to
take the vehicle if they do not breach the peace or break the law. If
there is any personal property in the vehicle when taken, Lessor can
take the property and store it for you. Any property attached to the
vehicle will stay with the vehicle. You agree to pay the reasonable
expenses of taking and storing the vehicle. You also agree to pay Les-
sor's reasonable attorney's fees if permitted by law.
23. lOSS OR DESTRUCTION OF THE VEHICLE. If the vehicle is lost,
stolen, destroyed, or determined by Lessor to be unsuitable for use, one
of the following will happen:
(a) This Lease will terminate early. You will owe Lessor the amount fig-
ured under Item 11. The amount of any insurance settlement will be
the sale price of the vehicle; or
(b) If you and Lessor agree in writing, you may continue this Lease with
a substitute vehicle. Any insurance settlement will be applied to the
purchase of the substitute veh icle.
.
24. LIFE AND DISABiliTY INSURANCE. If the life insurance described
in Item 8 is in force and payable and the insured person dies during the
Lease term, this Lease will terminate early. The insured's estate will owe
Lessor the amount figured under Item 11. The insured's estate must also
purchase the vehicle. The estate's purchase price will be substituted for
the sale price when figuring the amount owed under Item 11. The estates
purchase price will be the average of the retail and wholesale values of a
like. "clean" vehicle with the same options and without excess mileage.
Lessor will find these values in a then current guidebook Lessor selects.
The guideline for excess mileage will be the expected monthly mileage
from Item 9(b) times the number of months elapsed in the lease term, The
estate may obtain from an independent third party a professional appraisal
of the vehicle's wholesale and retail values that could be realized at sale.
The average of the retail and wholesate values from the appraisal will be
final and binding and will be the estate's purchase price. The estate must
pay for the appraisal. The estate and Lessor must agree on the appraiser.
If Lessor cannot get life and disability coverage for you, or if the cover-
age is cancelled before the end of the Lease. Lessor will credit any refunds
of unearned premiums paid to Lessor to your account. If your account IS
credited. Lessor will reduce your Monthly Payment.
25. SECURITY DEPOSIl: A refundable security deposit is part of the
payment you make when you sign this Lease. Lessor will deduct from the
security deposit any amounts you owe under this Lease and do not pay If
any part of the security deposit is left. Lessor will refund that part to you
after the end of the Lease.
26. INSPECTION. You agree to allow Lessor to inspect the vehicle at any
reasonable time and place. If Lessor asks to inspect the vehicle, you will
tell Lessor the location of the vehicle If the vehicle is damaged or there
is excessive wear and use. Lessor will decide if the vehicle should be
repaired. Upon request by Lessor. you agree to have vehicle repaired
promptly.
21INDEMNIT'f. You will protect Lessor and anyone to whom Lessor assigns
this Lease. from all losses. damages, Injuries. claims. demands. and
expenses arising out of the condition, maIntenance, use. or operatIon of
the vehicle. You agree to Indemnify and hold harmless Lessor and Its
assigns from all such losses, damages, injuries, claims, demands. and
expenses, You agree to pay Lessor for any loss or dama~e to the vehicle
during the Lease term,
28. DELIVERY RECEIPT. By signing thIS Lease, you agree that (1) you
received and examined the vehicle described in this Lease. (2) the vehi-
cle is as described in this Lease, and (3) the vehicle is in good operatIng
order and condition.
29. GENERAL. This Lease contains the entire agreement between you and
Lessor. There are no other agreements between you and Lessor pycept
those written in this Lease, No change will be valid unless In wtltinq and
signed by you and Lessor.
NOTICE TO LESSEE: 1. DO NOT SIGN THIS AGREEMENT BEFORE VOU READ IT. 2, YOU ARE ENTITLED TO A COPV OF THIS AGREEMENT.
YOUSIGNEDTHIS~R~'ENTM l-~~~ ~-- ~~~AN~:ECEI~O~COPYON~__:~~~~
LESSEE SIGNS. .. __~ . ~:~ ~~~~_ _..__~: ,
Lessor accepts thiS. ~ase.l!md a sjgn~ all right. title. and interest in this Lease and the vehicle described herein to oyl ptance Corpora-
tIon (GMAC) under the terms of the GMAC Lease_Plan oealerA_ _g_r_~1 nt_. _y(j (\ ~ 1 ~
.. 608 C~.r ~-~ P.. . .~ ~ /~
J.rt'w · Title
NOTICE: SEE OTHER SIDE FOR OTHER IMPORTANT AGREEMENTS.
4P..DROVEr AS Tn r(~ (""
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Please Remove All Carbons Before Signing.
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INSURANCE INFORMATION
1. LESSEE: ft... . (
Lessee N e Le0 k)~ Or-
C~ 1
Lessee Telephone No: Home (
Policyholder Name, if other than Lessee
Policyholder Address
~k)lUc.
State
ress ~~~L <1t~ ~ Lt)i Nl~ III:
ip~ ~~40
Business ( .~~) ~~ ~
Telephone No.
State _ Zip Code
City
.,.
Agent: -ERANK MCPHERSON
Agency:..I.HE PORTER ALLEN COMPANY
Address: 51 3 SOUTHARV STREET
KEY WEST. FLORIVA 33040
Policy No. HO 1 077922
InsuranceCompany INSURANCE CO. OF N. AMERICA
Effective Date: 03/15/90
Expiration Date: 0 3/1 5 / 9 1
Continuous? yes no X
'f.
Telephone No. ( 30 l)
) ?q4-?54?
FOLD
TO INSURANCE AGENT LISTED ABOVE
FOU
I have agreed to the lease conditions as follows:
Limit:
Public Liability~ $100,000/300,000 Bodily Injury, $50,000 Property Damage (Minimum) or $ 300 ,(x)() Combined Single Limit
ComQrehensive: ~ Deductible (Maximum) $1, 000. VEVUCTIBLE
Collision: ~ Deductible (Maximum) $1, 000. VEDUCTIBLE
NOTE: AS OWNER AND LESSOR OF SAID VEHICLE, GMAC MUST BE NAMED AS AN '1\DDITIONAL NAMED INSURED" AND "LOSS
PAYEE" ON ANY AND ALL INSURANCE COVERAGES APPLICABLE TO SAID VEHICLE INCLUDING LIABILITY COVERAGES. -
Such inclusion of lessor as "Additional Named Insured" and "Loss Payee" shall not operate to increase the limits of company liability.
Lessor shall receive notice by certified mail of any expiration, cancellation, or reduction of the insurance applicable to said vehicle. Such notice shall be
sent thirty (30) or the statutory minimum number of days prior to the effective date of such change to: GMAC, C/O POP SERVICES, 7TH FLOOR,
EXECUTIVE PLAZA ~ HUNT VALLEY, MARYLAND 21031, PHONE: poo-638-0SOO.
The vehicle described in Section NO.2 is replacing the following vehicle presently covered under the policy mentioned above:
Year: Make:
· Thank you for your cooperation.
Serial No.
2:ob
1-24-90
Lessee Signature
2. DEALER:
Dealership
\\lhide~.lption: Year Mate
!2!:!! Telephone \8ification of InMmInce Coverage:
Name of Person Contacted at Insurance Agency:
Verified by (Dealer Employe):
Date:
3. GMAC:
GMPC Branch
Branch No.
Dealer No.
Lease Contract No.
4. INSURANCE AGENT OR COMPANY REPRESENTATIVE (PLEASE SIGN AND MAIL IN ATTItCHED POSTAGE PAID ENVELOPE):
As an authorized represen1ative of the insurance company shown above, I agree to endorse the above policy as directed by lessee and certify coverage
for the vehicle described i . 2 as required under 0 lease provisions.
Date
I;/~/ f~
Agents Signature
nlE
PORTER-ALLEN COMPANY
INSURANCE
SINCE 1891
KEY WEST
513 Sout hard St.
Key \Vest, Florida 33040
(305) 294-2542
PLEASE PRINT OR TYPE TO PROVIDE FIVE LEGIBLE COPIES
-<.............~
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DIRECT LEASING PLAN
LESSEE STATEMENT
I BUSINESS I
GMAC
DIRECT
LEASING
PLAN
GMAC
DIRECT
LEASING
PLAN
(SEPARATE STATEMENT FOR EACH SIGNER OF THE LEASE)
TYPE OF BUSINESS YEAR ST ARTEO BUS. PHONE NO.
~LJ t51'1 T11ecT 44{,lJ. j
COUNTY ZIP CODE
JJ~ .~ ~~)
MKT. VALUE
IF OWNED: $
CHECKING ACCOUNT NO.
BUSINESS
CHECKING
ACCOUNT:
PREVIOUS BANK
IF ABOVE LESS
THAN 2 YEARS:
COMPANY FROM WHICH
LAST VEHICLE LEASED ~
OR FINANCED 0: y .
MAJOR TRADE REFERENCE:
CITY,.,..... I) ~T A TE
N.ll<<bettE1:
CITY STATE
BANK NAME
CHECKiNG ACCOUNT NO.
NAME ADDRESS CITY
cc - VY\ \(\-n1 t - eof> l~-
NAME ADDRESS CITY STATE
STATE
ZIP CODe MONTHl Y CHARGE
vY'\lfh711 Jl4I2If1l~~.
TELEPHONe NO. YEARS exPERIENCE
1.
POSITION
Da:ao~
YEARS ASSOCIATED
\ YY\{;L'Tt-!
~\
Hla55-1~d-4ry-d1to
NUMBER AND STREET
CITY
COUNTY
STATE
ZlPCOOE
TYPE 0 PROPRIETORSHIP
OF 0 PARTNERSHIP IN ADDITION. '':f?JfN
ORGANIZATION 0 CORPORATION OlUN ,C.\, I\-L,I
OR PROPRIETORSHIP, PlEASE COMPLETE REVERSE OF FORM.
and ICtIImL Gena Motors Acceptance Carpcntian or GIIAC Ltasinc Corporation is lutbWed to iMstipte ., credit .. II
witIt us.
LESSEE
,f&
-~
BY" Jam Stormont Title: Mayor /Chainnan
PROPOSED LEASE DATA
VEHICLE LEASE
MODEL 100000F:CA T10N NO. TERM
Q::Nfvfi 'Q~6'1N~~+54fcQ :io
Deputy Clerk
'- -- -----
YEAR MAKE
g() 601
PAVME~ SECURITY
,,~. DEPOSIT
~. ~
CAPITAL
(~~~
tNDICA TE IF MAJOR OPTIONS NOT INClUDEO ON VEHICLE:
o AlA CONDITIONING
o AUTO. TRANSMISSION 0 OTHIA(DESCFUIE)
Eof3 e.hf.HLJgo t lUC
BY
~ ~MTE 3 ~/GlJ
DEALERSHIP/AGENT
FOR OFFICE use
c;( 1:bJOA
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GMAC 870 0lP
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S'\'Ol~" STATEI\tE:\T UNDEJ~ SECTIOr\ 2S7.133(3)(a),
FLOJ~IDA STATUTES. ON PUnUC,EN1.ITI' CRIMES
THIS FO~'f !\fU5T BE SIGNED IN THE PRESENCE OF A NOTARY punuc OR OTHER OFFICER
AUTHORIZED TO ADMINISTER OATHS.
1. This sworn statement is submitted with Bid, Proposal or Contract No.
fur ONE 1990 BUICK 4 DOOR CENTURY
2.
BOB CHANGO, INC.
[name of entity submitting sworn statement]
3500 N. ROOSEVELT BLVD.
This sworn statement is submitted by
whose business address is
KEY WEST, FL. 33040
and
(if applicable) its Federal Employer Identification Number (FEIN) is
(If -the entity has no FEIN. include the Social Security Number of the individual signing this sworn
59-1805371
statement:
.)
3.
My name is
SAMUEL S. VaCI
(please print name of individual signing]
and my relationship to the
SECRETARY/TREASURER
4.
entity named above is
I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes.
means a violation of any state or.. federal law by a person with respect to and directly related to the
transaction of business with any public entity or with an agency or political subdivision of any other
state or with the United States, including, but not limited to, any bid or contract for goods or
services to be provided to any public entity or an agency or political subdivision of any other state
or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering,
conspiracy, or material misrepresentation.
<fII.
I understand that 'convicted" or 'convictiOn" as defined in Paragraph 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 trial coun 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 contendere.
5.
I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Fh;)rfda StntutelJ. means:
1. A predec.:ssor or successor of a person convicted of a public entity crime: or
2. An entity under the control of any natural person who is active in the management of the .
entity and who na! been convicted of a public entity crime. The term -affiliate- includes those
officers, directors, executives, panners, 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 ann's length agreement, shall be a priJoa 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
affiJia tee
.I understand that a "person" as defined in Paragraph 281.133(1)(e), flOrid, Stntute~ means any
natural person or entity organized under the laws of any state or of the United States with the legal
power t6 enter into a binding contract and which bids or applies to bid on contracts for the proVision
of goods or seJVices let by a public entity, or which otherwise transactS or applies to transact business
with a public entity. The tenn .person" includes those officers, directors, executives, partners,
shareholders. employees, members, and agents who are active in management of an entit)'.
Based on information and belief, the statement which I have marked below is true in relation to the
entity submitting this sworn statement. [Ph:llse Indicate which SUltement applies.]
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xx ~either the entitv submitting this sworn statement, nor any officers, directors. executives, . ,.
partners. shareholders. e-mployees, memhers, or agents who are active in management of the entity,
nor any affiliate of the entity have b~~n charged with and convicted of a public entity crime
subsequent to July 1, 1989.
The entitv submitting this sworn statemen~ or one or more of the officers, directors,
executives, partners. shareholders, employees. members, or agents who are active in 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, AliQ [Please indicate which additional statement applies.]
There has been a proceeding concerning the conviction before a hearing- officer of
the State of Florida, Division of Administrative Hearings. The fmal order entered by the
hearing officer did not place the person or affiliate on the convicted vendor list. [Please
attach a copy or the final order.]
_ The person or affiliate was placed on the convicted vendor list. There has been a
subsequent proceeding before a hearing officer of the State of Horida, Division of
Administrative Hearings. The final order entered by the hearing officer determined that it
was in the public interest to remove the person or affiliate from the convicted vendor list.
[Please nttach! copy of the finol order.]
_ The person or affiliate has not been placed on the convicted vendor list. [please
describe any action taken by or pending with e Department of General Services.]
Date:
4/12/9.0
STATE OF
COUNTY' OF
FLORIDA
MONROE
.,.
""
PERSONALLY APPEARED BEFORE ME, the undersigned ~uthorityt
SAMUEL s. VaGI
[name or lDdividual signing]
whot after first being sworn by me, affixed his/her signature
in the space provided above on this
12TH
day of APRIL. 19 90
-I' .
~
NOTARY PUBLIC;
My oommission ezpires: 11 /7 /92
,
: -
For::l PUR 7068 (Rev. 11/89)
"1.~~
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