03/28/1990 Statement Y
d Y r •` a.
I ,� SWORN STATEMENT UNDER 287.133(3)(a),
•
• FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
4
THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED TO ADMINISTER OATHS.
1. This sworn statement is submitted with Bid, Proposal or Contract No.
• for TT •
2. This sworn statement is submitted by Z4./lJt 6fr3C (-- .
1
[name of entity submitting sworn statement]
. whose business address is 130 CG I L1ri
OP)/ COL-K4' ( FC C .:.. 33v 5 Y and
4 s cos�a
• (if applicable) its Federal Employer Identification Number (FEIN) is
f
(If the entity has no FEIN, include the Social Security Number of the individual signing this sworn
statement: .)
3. My name is ,'44/& /77CAN and my relationship to the
[please print name of individual signing]
6
entity named above is e � r C . 6 r e. -
4. 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.
5. 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 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 contendere.
6 6. I understand that an 'affiliate' as defined in Paragraph 287.133(1)(a), Florida Statutes. means:
1. A predecessor 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
t entity and Who has been convicted of a public entity crime. The term ' affiliate' includes those
I 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 person who has been
- convicted of a public entity crime in Florida during the preceding 36 months shall be considered an
1, affiliate.
€ 7. 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
i power tb 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 an entity.
8. Based on information and belief, the statement which I have marked below is true in relation to the
entity submitting this sworn statement. [Please Indicate which statement applies.]
Neither the entity submitting this sworn statement, nor any officers, directors, executives; . . 1
p reners, shareholders, employees,
members, or agents who are active in management of the entity, '
nor any affiliate of the entity have 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 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, AND [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 final order entered by the
hearing officer did not place the person or affiliate on the convicted vendor list. [Please
attach a copy of 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 Florida, Division of
Administrative Hearings. The final order entered by the hearing officer determined that it
i was in the public interest to remove the person or affiliate from the convicted vendor list.
[Please attach a copy of the final order.]
x The person or affiliate has not been ! ". on the convicted vendor list. [Please
describe any action taken by or pending wi • th Depa .• - ' t of General Services.]
.,'i t/ ,
7urey _
} Date: r d
STATE OF FLORIDA
y
COUNTY OF MONROE
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
1 Aaron D. Allen who, after first being sworn by me, affixed his/her signature
[name of individual signing]
in the space provided above on this * -- day of e • _ • 19 • !_ .
Q.,.- -%/ --
iGl P.! —
NOTARY P : t;
My commission expires:
Notary Public, Stag of Florida
-. My Commission Expires Aug. 22, 1992
hnIed Thru Troy fain - Insurance Int,
1
:t Form PUR 7068 (Rev. 11/89)
7
*'1