05/09/1990 •
SWORN STATEMENT UNDER SECTION 287.113(3)(a),
FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
• 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
Contrapt pp. ` _ /
for �.. , ^�a ��r y' c�C� „J t � a f j c'' •
2. This statement is submitted by -ecu' 44
a i t C
(name of en submitting sworn statement)
whose business address is 9 /017 ) Ge. /(
and (if applicable) ' Federal,Emp oyer Identification
Number (FEIN) is, 4) 6 S'" OBI .5 i (If the
entity has no FEIN, include the Social Security Number
of the individual signing this sworn statement:
3. My name is \id 1 r
(please pri , -�e,,� individual signing)
entity named above is -
4. I understand that a 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 bi
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. 1 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 entity and who
has been convicted of a public entity crime. 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 person who has been
convicted of a public entity crime in Florida during
the preceding 36 months shall be considered an
affiliate.
7. I understand that a "person" as defined in Paragraph
287.133(1)(e), Florida Statutes means 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
0 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.)
X Neither the entity submitting this sworn statement, nor
any officers, directors, executives, partners, 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.
� Lat e ,uenc, 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 was in the public interest to remove the person
or affiliate from the convicted vendor list. (Please
attach a copy of the final order).
The person or affiliate has not been placed on
the convicted vendor list. (Please describe any action
taken by or pending with the Department of General
Services.)
(signature)
Date: 7 R �/ 9t
STATE OF Fie, r; c1 ca
COUNTY OF 01 Ca r1 r n e
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
a )1 E u r n:S who, after first being sworn by me,
(name of individual signing)
affixed his /her signature in the space provided above on this
.e9/ day of,� 19 "7d.
NOTAR U C
•
My commission expires: Al /7 / 9