File Ref. #104
KeF /~ i/.-J6j1 r 29/ /9 f?
SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a).
FLORIDA STATUTES. ON PUBLIC ENTITY CRIMES
THIS FORM MlJST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PLJBLlC OR OTHER OF....CIAL
AliTHORIZED TO ADMINISTER OATHS,
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
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
statement( .)
2 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 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( I )(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 I, 1989, as a result ofajury verdict, non-jury trial, or entry ofa plea of guilty or nolo
contendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133(1 lea), Florida Statutes. means:
I. 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 ora public
entity crime. The term "affiliate" includes those officer, directors, executives. partners, shareholders, employees, members, and agents
who are active in the management ofan 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.
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 ofan entity.
6. Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted of a public entity crime subsequent to July I, 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 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 I, 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 I, 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 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 linal order)
<:c
I l'\IlEH.ST\';() 111\1 IIIE SIR\lISSIO'\ OF TIllS FOH.\I 10 1111: CO'\IR\CII'\(; OHICEH. FOH.IIIE PI BII( 1:'\111'
IIHSIHIEIl .'\ P.\R\(;R.\PII . (O'\Fl ABon: IS FOH. TlL\I I'lBIIC E'\llTY O'\IY\'\D, TlI \I IIIIS HlH.\1 IS \.\IJ1l
IIIH.On;IIIHTDIBEH. 31 OF TIlE C\IE'\IHH. YEAH. 1'\ WIIICIIII IS F1IEIl. I .\ISO I'\DFH.ST\'\!) 111.\1 I .\\1 H.H)IIH.11l
10 I'\H)R\I IIIE I'lBII( E'\T1n PRIOR TO E'\TERI\G I\TO .\ CO\IR\CT 1\ EXCESS OF TilE TIIRESIIOIIl .\ \101 \1
PRO"'IHIlI\ SEeTIO\ 2H7.1117. FI.ORm\ ST\T\n:s FOR c\n:(;ORY TWO OF .\\Y ('II\\(,E 1\ TilE I\FOR\L\T10\
CO'\T\I'\EIlI\ TillS FOR\!.
(Signature)
(Date)
ST\n: OF
COI'\IY OF
PERSO:'-iAILY APPEARED BEFORE !\IE.the undersigned authority. _~_________
\\l1l1
aller lirst helng s\\orn hy me. artixed his/her signature in the space provided ahove on this
_~__._.__ day of _____
.1'1
NOTARY PlJBl.IC
My Commission Expires:
FORM PUR 7068 (Rev 06105/91)
SWORN STATEMENT PlJRSUANT TO SECTION 287.133(3)(a).
FLORIDA STATUTES. ON PlJBLlC ENTITY CRIMES
THIS FORM MllST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OF....CIAI.
AllTHORIZED TO ADMINISTER OATHS,
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
and (if applicable) its Federal Employer Identification Number (FEIN) is
(If the entity has no FEIN,
statement: (
include the Social Security Number of the individual signing this sworn
.)
2. 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 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( I )(b), Florida Statutes. means a finding of guilt or a
conviction ofa 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 I, 1989, as a result of ajury verdict, non-jury trial, or entry of a plea of guilty or nolo
contendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133(1 )(a), Florida Statutes. means:
I. 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 officer, 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.
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 an entity.
6. Based on information and belief, the statement which I have marked is true in relation to the entity submitting this sworn statement.
(indicate which statement applies.)
Neither the entity submitting this swom statement, nor any of its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted of a public entity crime subsequent to July I, 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 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 I, 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 I, 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 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 tinal order)
I 1....IHI{SIT\1> 1l1\T IlIE SIH\IISSIO.... OF IlllS "Ol{\! TO 1m: COYIR\<IT\t; OFFlt'El{ Fell{ IIIE PI HII( '....11"
IIHSIHIUl I.... I'\R\C;R\I'1I I (O....E) .\Hon: IS 1'01{ TlI.\T nHUC E....T1TY O....IY\....I>, TlI \T TillS HlI{\' IS \.\UIl
IIIlWI(;IIIlHDIHER 3101' TilE C\IE....IHR YEAR I.... WlIIClIlT IS FILED. I ALSO 1.....I>FRST\....n TII\T 1\ \! RH)IIIUIl
10 I....HlI{\! TilE 1'1 HUt E....Tln I'RlOR TO ISIERI....G I....TO A CO....IR\CT I.... EXCESS OF TilE TIIRESIIOIIl .\\IOISI
I'RO\mUl I.... SUllO.... 2H7.017, F1.0RID.\ SL\Tln:s FOR C\TEGORY TWO OF .\....Y nL\....t;E I.... TilE I....FOR\'.\TIO....
('O....T\I....EDI.... TIllS FOR\!.
(Signature)
ST\n: OF
( Date)
('01.... IT OF
PERSO"iAI.l.Y AI'PL\RED BEFORE ME. the undersigned authority. _~._.___
\\hn
aller tlrst heing morn hy me. affl\ed his/her signature in the space provided ahove on this
day "I'
Il)
NOTARY PUBLIC
My Commission hpires
FORM PUR 706S (Rev 06/05/91)
SWORN STATEMENT PURSUANT TO SECTION 287,133(3)(a).
FLORIDA STATUTES. ON PlJBLlC ENTITY CRIMES
THIS FORM MlIST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PllBLlC OR OTHER OFFICIAL
AUTHORIZED TO ADMINISTER OATHS,
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
and (if applicable) its Federal Employer Identification Number (FEIN) is
(If the entity has no FEIN,
statement:(
include the Social
.)
Security Number of the
individual
signing this sworn
2. 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 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( 1 )(b), Florida Statutes. means a finding of guilt or a
conviction ofa 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 ajury verdict, non-jury trial, or entry of a plea of guilty or nolo
contendere.
4. 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 entity and who has been convicted of a public
entity crime. The term "affiliate" includes those officer, 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 ajoint venture with a person who has
been convicted ofa 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. I 33(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 appl ies 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.
6. Based on information and belief, the statement which 1 have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted of a public entity crime subsequent to July], 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 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 agenrs 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 I, 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 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 1 :\IHR"iT\:\1) TII\! TIlE SIII\IISSIO:\ OF TIllS FOR\I TO IIn: COYlR\(TI:\C; OFFICER FOR TilE PI Bllt F:\III'
IIHSIIHUl 1:\ !'\R\(;R.\I'II I (O:\Fl ABO\E IS FOR TlI.\! PIBIIC ~snn O:\IY\:\Il, I'll\! TIllS FOR\! IS \\1I1l
IIIROIC;1I IlUT\IHER 31 OF TilE C\IE:\'HR YEAR I" WlIICIIIT IS FILED. I ALSO l"IlERST\"D Ill.\! I \ \I RU)IIlUIl
10 I:\HlR\I TilE !'IIH.I( DillY PRIOR 10 EYIERI"G 1\1'0 A COYlR\CT I" EXCESS OF TilE TlIRESIIOIIl .UIOlYI
!'RO\IIlU) '" SUTIO" 2!17.017, FIORIlH ST.\T1TES FOR L\ITGORY TWO OF A:\\ ClL\:\(.E 1:\ TilE I:\HlR\I.\!IO\
(O:\T\I:\Ul I" TillS FOR'"
(Signaturr)
(Datr)
ST\n: O~
(01 SI\ OF
PERSO"lAII.Y Al'PL\RED BEFORE !\IE. the undersigned authority, ____._..._
\\l1n,
aller IIrst heing s"orn hy me, affixed his/her signature in the space provided ahove on this
day of
1'1
NOTARY PUBl.IC
My Commission Expires:
FORM PUR 7068 (Rev 06105/91)
SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a).
FLORIDA STATUTES. ON PUBLIC ENTITY CRIMES
THIS FORM MlJST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PllBLlC OR OTHER OFFICIAL
AUTHORIZED TO ADMINISTER OATHS,
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
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
statement:( .)
2 I understand that a "public entity crime" as defined in Paragraph 287 .133( I )(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( I )(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 I, 1989, as a result of ajury verdict, non-jury trial, or entry of a plea of guilty or nolo
contendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133(1 )(a), Florida Statutes. means:
I. 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 officer, 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 ofa 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 ofan entity.
6. Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees. members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted of a public entity crime subsequent to July I, 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 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 I, 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 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 I :\IlER'iT\:\IlIIlH TilE SIB\lISSIO:\ OF TillS FOR\1 TO IIn CO:\TR\(TI:\(; OFFICEI{ 1.01{ TIIF PI BII( F:\ f II'
IIHSIHfEIl 1:\ 1'.\R\(;IUI'II I (O:\F) \Bon: IS FOI{ TlI.H PIBIIC E:\TITY O:\lY\:\Il, TlIH TIllS FOI{\1 IS \\11/)
f1IlWI(;1I DEn:\1BEI{ 31 OF TilE (',\lE:\IHI{ n:.\H 1:\ WIIICIIIT IS FilED. I \lSO 1:\IlEHST\:\1l IIIH I .\\! HH)IIHlll
10 I:\FOR\! TilE l'lBII( E:\TlTY I'HIOH TO ~SIEHI:\(; 1:\1'0 \ CO"IR\CT 1:\ nCESS OF TilE IIIHESllOlD .\\10ISI
I'HO\lIlUl 1:\ SECTlO:\ 2!l7.1117, FlOHm\ ST\Tln:s FOH C\IT(;OHY TWO OF .\:\Y ('II\:\(.E 1:\ TIlE I:\FOH\I.\TlO:\
(O:\T\I:\Ul 1:\ TillS FOH\1.
(Signature)
sun: OF
(Ilale)
(O! sn OF
I'EHSO'-i\II.Y AI'I'L\HED BEHlHE I\1E. the undersigned authority. ~_~______~_____
. \\l1n
alter lirsl heing sworn hy me. ani,ed his/her signature in the space provided ahove on this
day 01'_
I')
My Commission I'xpires:
NOTARY PI]flUe
FORM P(JR 7068 (Rev 06/05/91)
SWORN STATEMENT PlJRSlJANT TO SECTION 287.l33(3)(a),
FLORIDA STATUTES. ON PlIBLlC ENTITY CRIMES
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PllBLlC OR OTHER OFFICIAl.
AUTHORIZED TO ADMINISTER OATHS,
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
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
statement:( .)
2 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 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(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 I, 1989, as a result of ajury verdict, non-jury trial, or entry of a plea of guilty or nolo
contendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes. means:
I. 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 officer, directors, executives, partners, shareholders, employees, members, and agents
who are active in the management ofan 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.
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, sbareholders, employees, members, and agents
who are active in management of an entity.
6. Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted of a public entity crime subsequent to July I, 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 the management of the entity, or an affiliate of the entity bas been cbarged
with and convicted of a public entity crime subsequent to July I, 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 ofa public entity crime subsequent to July I, 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 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 I '\I>EHST\'\I>IIIH IlIE SIH\IISSI0.'\ OF .IIIS FOH\1 .0 '"I: COYIR\C 11,\(; OHICEH FOHI liE PI 1111( L'\ III'
IIlIYIH III> 1'\ !'\R\(;R.\I'II I (0'\1) .\HO"I IS FOH TlI.\1 PIHUC I'\TI" 0'\1'\'\1>, '"\, .IIIS HlH\' IS \ \I.1l>
IIIH0n;II I>EeDIHEH JI OF .IIE C\LE'\IHH 'E.\H 1'\ WIIICIII. IS FlU:I>. I .\LSO l'\I>EHST\'\1> 111.\' 1\" HEe)1 IIHI>
'0 I'\HlH\' TilE !'IHU( E'\TlT' I'H(OH TO E'\TEHI'\G ('\TO\ COYI R\(T 1'\ EXO:SS OF TIlE TlIHESIIOII> .\\101 '\1
!'H()\IIHI> 1'\ SHTIO'\ 1H7,()]7. FLOHIIH STATln:S FOR C\IU;ORY TWO OF A'\Y ClL\'\(.E 1'\ 'IIE I'\HlR.\I.HIO'\
(O"T\I"EI> I" TillS FOR\L
(Signaturr)
(nalr)
sun: OF
COI'\" OF
I'ERSO"ALLY AI>I'L\RED HEFORE \IE. the undcrsigncd authority. ~~~~_._._~______
. "hi)
altcr lirst hcing s\\orn hy mc. afli\cd his/hcr signaturc in thc spacc providcd ahove on this
day of
III
NOTARY PUBLIC
My COl1lmission F\pires.
FORM PUR 706X (Rcv 06/05/91)
SWORN STATEMENT PlJRSUANT 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
AllTHORIZED TO ADMINISTER OATHS.
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
and (if applicable) its Federal Employer Identification Number (FEIN) is
(If the entity has no FEIN,
statement: (
include the Social
)
Security Number of the
individual
signing this sworn
2. 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 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( I )(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 infonnation after July I, 1989, as a result ofajury verdict, non-jury trial, or entry ofa plea of guilty or nolo
contendere.
4. I understand that an "affiliate" as defined in Paragraph 287. 133(1)(a). Florida Statutes. means:
I. 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 ofa public
entity crime. The tenn "affiliate" includes those officer, 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 he
a prima facie case that one person controls another person. A person who knowingly enters into ajoint 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
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 appl ies 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 tenn "person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents
who are active in management ofan entity.
6. Based on infonnation and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted of a public entity crime subsequent to July I, ] 989.
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 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 I, 1989.
The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders,
employees members, or agent.s 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 I, 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 detennined that it was not in the public interest to place the entity submitting this sworn statement on thc
convicted vendor list. (attach a copy orthe final order)
I I '\IHI{SI\'\Dlll.\T TilE SIH'\IISSIO'\ OF TillS FOI{'\1 TO IIU: ('O'\IR\CTI'\(; OHICEI{ ,.()I{ TIIF PI HI/( E'\III'
IIHSIIHEIl 1'\ I'\R\(;R\I'II I (O'\F) .\Hon: IS FOI{ TInT PIHI/C E'\ITn O'\U\'\Il. TlI \T TillS FOI{'\1 IS '\ .\1111
11I1{01(;IIIHTDlBEI{ 31 OF TilE ('.\IE'\I)\1{ YE\I{ 1'\ WIIICIIIT IS FII.ED. I \ISO I''\IHI{ST\'\DIII.\T I .\ ,\II{H)III{I'1l
10 I'\HIR'\1 TilE PIHI.I( E'\TITY PI{IOI{ TO E'\TEI{I'\(; I'\TO .\ CO'\IR\CT 1'\ EXCESS OF TilE TIII{ESIIOID .\ '\101 "1,1
PI{O,\'IDED 1'\ SECTlO:\ 2!l7.017, FI.ORIIH SL\Tln:s FOR ('.\TEGORY TWO OF .\'\Y ClL\'\(.E 1'\ TilE I'\FOR\I.\TIO'\
CO'\T\I'\E1) 1'\ TillS FOR'\!.
(Signaturr)
(Date)
ST\n: OF
COI'\ n OF
PERSO"i\LLY \PPL\RED BEFORE '\IE. the undersigned authority.
\\110
afkr first oeing S\\Ofl1 oy me, afli\ed his/her signature in the space provided aoove on this ______~____ day of
. I')
NOTARY PUBLIC
My Commission Expires
rORM PUR 70(,8 (Rev 0(,/05/91)
SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a).
FLORIDA STATUTES, ON PlIBLlC ENTITY CRIMES
TIllS 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
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
and (if applicable) its Federal Employer Identification Number (FEIN) is
(If the entity has no FEIN.
statement: (
include the Social Security Number of the individual signing this sworn
.)
2 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 of the United States, including, but not limited to, any bid or contract for goods or serv ices 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( I )(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, non-jury trial, or entry of a plea of guilty or nolo
contendere.
4. 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 entity and who has been convicted of a public
entity crime. The term "affiliate" includes those officer, 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 ajoint venture with a person who has
been convicted ofa 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 an entity.
6. Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted of a public entity crime subsequent to July I, 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 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 agent.s who are active in the management of the entity, or an affiliate of the entity has been charged
with and convicted ofa public entity crime subsequent to July I, 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 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 I '''HRST\,\I)III.H Till SIU\IISSIO'\ OF TillS FOR\' TO 1m: CO'\TK\C 1('\(; OHICIR FOR 1111 nU1.1( /'\111'
IIH'\IHIEll 1'\ I'\K\(;K\I'II I (O'\E) \RO\'I IS FOR TlIH rnu.lc I'\TITY O,\I.Y\'\I), TlIH TillS HlR\' IS \.\(11)
IIIROI(;IIIHTL\lHIR 31 OF Till C\I.I,\I)\R n:.\R 1'\ WIIICIIIT IS FILII), I .\I.S0 I'\I)IRST\,\(} TlI.H I .\\1 RH)IIRI(}
10 I'\FOR\' Till !'IUII( E'\ITn PRIOR TO EYIERI,\(; I'\TO \ COYIR\CT 1'\ EXCESS OF TIlE TIIRESIIOI.I) .\\)OISI
!'RO\'IIlEll 1'\ SHTIO'\ 2117.flI7, FI.ORII>.\ ST\T\n:s FOR c\n:(;ORY TWO OF .\'\Y C11\,\(;E 1'\ TilE I'\HlR\I.HIO'\
CO'\T\I'\EI) 1'\ TillS FOR\!.
(Signaturc)
(Date)
ST\n: OF
COI'\ n OF
l'ERSO'-lAI.I.Y AI'PL\REIl BEFORE \'E. the undcrsigncd authority,__
\\11(1,
allcr first hcing s"orn hy mc, affixcd his/hcr signaturc in thc spacc providcd ahovc on this ______~__.___ day of ___
I')
NOTARY PUBLIC
My Commission Expires
FORM PUR 70(,8 (Rcv 0(,/05/91)
SWORN STATEMENT PIJRSIJANT TO SECTION 287.I3J(J)(a).
FLORIDA STATUTES. ON PIJBLlC ENTITY CRIMES
THIS FORM MIIST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PIIBLlC OR OTHER OFFICIAL
AIITHORIZED TO ADMINISTER OATHS,
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
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
statement:( .)
2 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 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( I )(b), Florida Statutes. means a finding of guilt or a
conviction ofa 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 I, 1989, as a result of ajury verdict, non-jury trial, or entry of a plea of guilty or nolo
contendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133(1 )(a), Florida Statutes. means:
I. 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 officer, 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.
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 appl ies 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 ofan entity.
6. Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the 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 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 I, 1989.
The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholdcrs.
employees members, or agents who are active in the management of the entity. or an affiliate of the entity has heen charged
with and convicted of a public entity crime subsequent to July I, 1989. However, there has heen a subsequent proceeding
before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered hy 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)
II '\IHRST\'\DIIIHIIIE SIH'"SSIO.' O~ TillS FOR\! TO 1m: COYIR\CII,\(; OFFHTR ~OR III' rlHl.1< "III'
IIHSIHIUl 1'\ P\R\(;R.\I'II I (O'n .\HO\E IS FOR TlI.\T PIHIIC E'TIT\ 0'\1' .\'\Il, '"\T TillS HlH'l IS \.\1111
IIIRon;1I DHT\!H'R 31 OF TilE ('\I"/).\R 'EAR 1'\ WIIICII IT IS FII.ED. 1 \ISO 1''\IHHSI\'IlIIl.\T 1\\1 RH)IIRIIl
10 "HlH'\I TilE I'IHIIC ~srlT\ PRIOR TO "TERI:\C; I'\TO A COYIR\CT 1:\ EXCESS OF TIlE TIIRESIIOLIl .\'\101 'I
I'RO'IIlUl 1'\ SECTlO'\ 2117,1117, FI.ORm.\ STAT! n:s FOR c\n:(;OR\ TWO OF .\'\\ C1L\'\GE 1'\ TilE I'\HIR\L\TlO'\
CO'\T\I'\rD 1'\ TIllS FOR'!.
(Signature)
ST\n: OF
(l)atc)
CO!, n OF
I'ERSO'\AI.I.\ APrE,,\RED HEFORE \IE, thc undcrsigncd authority, ~_____~_
. \\l1u,
allcr first hcing sworn hy mc, affixcd his/hcr signature in the spacc providcd ahovc on this_______.__ day of_ _
, I')
NOTARY PlIBLlC
My Commission Expircs'
FORM PlIR 70(,8 (Rcv 0(,/05/91)
SWORN STATEMENT PlJRSlJANT TO SECTION 287.I3J(J)(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.
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
and (if applicable) ils Federal Employer Identification Number (FEIN) is
(If the entity has 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(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 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(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 I, 1989, as a result of ajury verdict, non-jury trial, or entry of a plea of guilty or nolo
contendere.
4, I understand that an "affiliate" as defined in Paragraph 287,133(1 )(a), Florida Statutes, means:
I. 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 officer, directors, executives, partners, shareholders, employees, members, and agenls
who are active in the management of an affiliate, The ownership by one person of shares constituting a controll ing 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 ofa 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 hid 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.
6. Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have bcen
charged with and convicted of a public entity crime subsequent to July I, 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 the management of the entity, or an affiliate of the entity has heen 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, shareholdcrs,
employees members, or agent.s who are active in the management of the entity, or an affiliate ofthe entity has heen chargcd
with and convicted of a public entity crime subsequent to July I, 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 hy thc
Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on thc
convicted vendor list. (attach a copy of the final order)
I I '\IHR'iT"IlIlI\TIIIF SLH\IISSIO.' OF TillS FOR\I TO IIIE CO'\TR\(TI'\C; OFFICER FOR TilE PlIlU( F'\ IIn
IIH'\T1FIFIl 1'\ I'\R\C;R\I'II I (O'\r)\Ron: IS FOR TlL\T rLHUC ~sl(n 0'\1'\,\1), TII\T TillS HlR\I IS \.\UIl
IIIROI(;IIIHTE\lHER 31 OF TilE C\I.E'\IHR YEAR 1'\ WIIICII IT IS HI.EIl, I .\LSO l'\IlERST.\'\1l TII\T I .\ 'I RH)I IRFIl
10 I'\HlH\I TilE I'LHUC ~sITn PRIOR TO ~srERI'\G (,\TO \ CO'\IR\CT 1'\ EXCESS OF TilE TIIRESIIOI.Il A \I0l 'I
I'RO\lIlln 1'\ SFCTIO'\ 2117,()17, FLORIIH STATln:s FOR C\TEGORY TWO OF \'\Y C1L"C.E 1\ TilE I\HlR\L\IIO\
CO'\T\I'\EIlI'\ TillS FOR'!.
(Signature)
sun: OF
(Ilatc)
COL\n OF
I'ERSO'-lAI.!.Y AI'PL\RFI) BEFORE 'IE, the undcrsigncd authority, ____.".~___~___
\\Ih\
allcr Iirst hcing sworn hy mc, affixed his/hcr signature in the space provided ahove on this ________~__~__ day of
I')
NOTARY PUBl.IC
My Commission Expires:
FORM PUR 7()('8 (Rcv O('/()5/91)
SWORN STATEMENT PURSlJANT TO SECTION 287.133(J)(a).
FLORIDA STATUTES, ON PliBLlC ENTITY CRIMES
THIS FORM MllST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PIIBLlC OR OTHER OFFICIAL
AIITHORIZED TO ADMINISTER OATHS.
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
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
statement:( .)
2. 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 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( I )(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 I, 1989, as a result of ajury verdict, non-jury trial, or entry of a plea of guilty or nolo
contendere.
4. I understand that an "affiliate" as defined in Paragraph 287, 133(1)(a), Florida Statutes, means:
I. 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 ofa public
entity crime. The term "affiliate" includes those officer, 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 affil iate.
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 an entity.
6. Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted of a public entity crime subsequent to July I, 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 the management of the entity, or an affiliate of the entity has been chargcd
with and convicted of a public entity crime subsequent to July I, 1989.
The entity submitting this sworn statement, or one or more of its officers, directors, executivcs, partners, shareholders.
employees members, or agent.s who are active in the management of the entity, or an affiliate of the entity has hcen charged
with and convicted of a public entity crime subsequent to July I, 1989. However, there has been a suhsequent proceeding
before a Hearing Officer of the Statc of Florida, Division of Administrativc Hearings and the Final Ordcr cntered hy thc
Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statcment on thc
convicted vendor list. <attach a copy of the final order)
I I '\IlERSI.\'\IlIIl.\1 TIlE SIB\IISSIO'\ OF TillS FOR\I TO lilt-: CO'\IR\C 1('\(; OFFICER FOH 'liE ['IBU( E'\ II"
IIHSIHIEIl 1'\ I'.\R\C;R.\I'II I (O'\E) .\HOVE IS FOR '"\T rlBUC E'\Tln O'\I.Y\,\Il, '"\, 'illS HlH\I IS \\UIl
IIIROI(;III)HDIIIER 31 OF TilE C\I.E'\IHR n:.\R 1'\ WIIICIIIT IS F1LEIl, I .\I.S0 1'\IlERST\'\!l TlI \T I .\ \I RH)I IIUIl
10 I'\HlR\I TIlE ['IBU( E'\Tln PRIOR TO E"dERI'\G I\TO\ CO:\IR\CT 1'\ EXCESS OF TIlE TlIHESIIOLIl .\\101 :\1
I'RO\'lIlEIlI'\ SECTIO'\ 2117,(117, FLORJI)\ ST.\T\n:s FOR C\n:GOR\ TWO OF .\'\Y C1L\\(.E 1'\ TilE I'\HlH\I.\TlO'\
CO'\T\I'\EIlI'\ TillS FOR'!.
(Sign~lurc)
(Ilale)
sl.\n: OF
COI SIT OF
I'ERSO'-lAI.L \ AI'PL\REIl BEFORE !\IE, [hc undcrsigncd authority,._
\\h\\
allcr lirst hcing s\\orn by mc, affixcd his/hcr signaturc in thc spacc providcd ahovc on this ___
day of
, I'}
NOTAR Y PUBLIC
Mv Commission Expircs'
FORM PUR 70(,8 (Rcv 0(,/0)/91)
SWORN STATEMENT PURSUANT TO SECTION 287.IJJ(J)(a),
FLORIDA STATUTES. ON PIIBLlC ENTITY CRIMES
TIllS FORM MIJST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PIIBLlC OR OTHER OFFICIAL
AIITlIORIZED TO ADMINISTER OATHS.
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
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
statement:( .)
2. 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 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(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 I, 1989, as a result of ajury verdict, non-jury trial, or entry of a plea of guilty or nolo
contendere.
4, I understand that an "affiliate" as defined in Paragraph 287, 133( I )(a), Florida Statutes, means:
I. 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 officer, 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 ofa 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( 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 an entity,
6. Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted of a public entity crime subsequent to July I, 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 the management of the entity, or an affiliate of the entity has been charged
with and convicted ofa public entity crime subsequent to July I, 1989.
The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholdcrs,
employees members, or agents who are active in the management of the entity, or an affiliate of the entity has heen chargcd
with and convicted of a public entity crime subsequent to July I, 1989. However, there has been a suhsequent proceeding
before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered hy the
lIearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on thc
convicted vendor list (attach a copy of the final order)
11'\llFHSI\'\/lIII\T IIIE SIH\lISSIO'\ OF TillS FOR\! TO nn: CO,\TR\CI('\(; OHJ<ER FORIIIE rlBlI1 E'\III\
IIH.'\T1FIUl 1'\ P.\R\l;R.\P1I I (0'\.:) .\BOVE IS FOR TII\T PIBIIC E'\T1TY O'\I.Y\'\/l, TlI \T TillS FOR\! IS \ \I III
IIIROI(;IIIHTDIHER 31 OF TilE C\U,\[HR 'T\R 1\ WIIICIIIT IS FIlE/l, I .\I.S0 I',\IHRSL\,\() TlI\T 1\ \I RH)IIRI/l
10 1\1-0R\! TilE I'lHII( E'\TITY PRIOR TO E\TERI'\G "TO \ COYIR\CT 1'\ EXCESS OF TilE TlIRESIIOI./l .\\I0l 'I
I'Ro\'IDFI> " SHTIO\ 2117,f)I7, FLORID\ ST\Tln:S FOR C\n:(;ORY TWO OF \'\Y C1L\,\(;E 1'\ TilE I'\HlR\!.\IIO\
CO'\T\I\EI> 1'\ TillS HlR\!,
(Signature)
(/late)
ST\n: OF
COI SlY OF
l'ERSO'-lALLY AI'PL\RE/l BEFORE ME, the undcrsigncd authority, __~~_.._~___.. ________~_ _....__
\,Ill)
altcr first hcing sworn hy mc, affixcd his/hcr signaturc in the spacc prnvidcd ahove on this ___.
day of
19
NOTARY PUBLIC
My Commission Expircs:
FORM Pl!R 7()('8 (Rcv ()('/OS/91)
SWORN STATEMENT PIJRSIJANT TO SECTION 287,I3J(J)(a),
FLORIDA STATUTES. ON PUBLIC ENTITY CRIMES
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PIIBLlC OR OTHER OFFICIAL
AIITlIORIZED TO ADMINISTER OATHS.
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
and (if applicable) its Federal Employer Identification Number (FEIN) is
(If the entity has no FEIN,
statement:(
include the Social
.)
Security Number of the
individual
signing this sworn
2. 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 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( I )(b), Florida Statutes, means a finding of guilt or a
conviction ofa 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 I, 1989, as a result of ajury verdict, non-jury trial, or entry of a plea of guilty or nolo
contendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133(1 )(a), Florida Statutes, means:
I. 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 puhlic
entity crime. The term "affiliate" includes those officer, 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 ajoint venture with a person who has
been convicted ofa public entity crime in Florida during the preceding 36 months shall be considered an atTiliate
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 husiness with
a public entity. the term "person" includes those officers, directors. executives, partners, shareholders, employees, memhers, and agents
who are active in management ofan entity.
6. Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted of a public entity crime subsequent to July I, 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 the management of the entity, or an affiliate of the entity has bcen charged
with and convicted of a public entity crime subsequent to July I, 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 heen chargcd
with and convicted ofa public entity crime subsequent to July I, 1989. However, there has been a subsequent proceeding
before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Ordcr cntered hy thc
Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on thc
convicted vendor list (attach a copy of the final order)
I I '\IlER"T\'\1l 111\1 TilE SIH\IISSIO'\ OF TillS FOR\I TO 'liE CO'\TR\( 1('\(; OHHER FOR IIIF PIBII( F'\ III \
IIH'\III-1Ul 1'\ I'\R\(;R\I'II I (O'\El .\Bon: IS FOR TII\T rlHUC E'\TIT\ 0'\1\ .\'\Il, TIIU TIllS HlR\I IS \.\UIl
IIIRon;IIIH:n:\IBER 31 OF TIn: (',\I.E'\O.\R \E\R 1'\ WlIIeII IT IS F1U]l, I .\I.SO 1''\IlERSL\'\/l1 II.U 1\\1 RH)IIIUIl
'0 I'\HlR\I TilE I'IHU( E'\Tln PRIOR TO E'\TERI'\G I'\TO \ CO'\IR\CT 1'\ EXCESS OF TilE TIIRESIIOI.Il .\ \101 '\1
I'RO\IIHI) 1'\ SHTIO'\ 2117,()17, FUlHlIH SL\Tln:s FOR C\n:GOR\ TWO OF .\'\\ C1L\'\(.E 1'\ TilE I'\HlR\l.UIO'\
(O'\T\I'\EIlI'\ TillS FOR\I,
(Signature)
SlUE OF
(Ilatc)
(01 SI\ OF
l'ERSO'-lAI.L\ APPL\REIl BEFORE 'IE, the undcrsigncd authority, ~_____________..
\\h\\
altcr lirst ncing s\\orn hy mc, affixcd his/hcr signaturc in thc spacc providcd anove on this _~________ day of
I')
NOTARY PUBLIC
My Commission Expircs'
FORM PUR 70(,8 (Rcv ()('/OS/91)
SWORN STATEMENT PIJRSUANT TO SECTION 287.133(3)(a),
FLORIDA STATUTES. ON PlIBLlC ENTITY CRIMES
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL
AlJTHORlzt:D TO ADMINISTER OATHS.
I. This swom statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
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
statement:( .)
2. 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 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( I )(b), Florida Statutes, means a finding of guilt or a
conviction ofa 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 ajury verdict, non-jury trial, or entry of a plea of guilty or nolo
contendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133( I )(a), Florida Statutes. means:
I. 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 officer, 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.
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, membcrs, and agents
who are active in management ofan entity.
6. Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted ofa public entity crime subsequent to July 1, 1989.
The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholdcrs,
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 I, 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 chargcd
with and convicted of a public entity crime subsequent to July I, 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 hy thc
Hearing Oflicer determined that it was not in the public interest to place the entity submitting this sworn statement on thc
convicted vendor list. (attach a copy of the final order)
I I '\IlERST\'\DIIIU TilE SIII\IISSIO'\ OF TillS FOR\I TO IIn: CO'\IR\('I(,\(; OHHTR I-OR TilE 1'1111.1< 1-'\111 \
IIH'\TlHEIl 1'\ P.\R\(;R\I'II I (O'\E) .\Bon: IS FOR TII\T PlBI.IC E'\TlTY O'\IY\,\Il, TIIU TillS FOR\I IS \.\1.I1l
IIIROI UllHTnlllER 31 OF Tilt: C\I.E'\O.\R n:.\R 1'\ WIII('IIIT IS Flu:n. I .\I.SO l'\nERST\'\!) TII.U I .\\1 RH)II RI!)
10 I'\I-OR\I TilE PlBI.H E'\Tln PRIOR TO ~SIERI'\(; I'\TO \ CO'\TR\CT 1'\ nCESS OF TIlE TIIRESIIOL!) .\\lOISI
I'RO\'lnEl) 1'\ SUTlO'\ 2!l7,1l17, FI.ORIIH STAT! n:s FOR c\n:(;ORY TWO OF .\'\Y ('IL\'\(.E 1'\ Till I'\FOR\I.\TlO'\
(O'\T\I'\En 1'\ TillS FOR\I,
(Signature)
ST.\n: OF
(I)atc)
COI SlY OF
I'ERSO'oJALLY APPEARED BEFORE I\IE, thc undcrsigncd authority. ~___________.______
. \\il'.1
allcr ",rst hcing s\\orn hy mc, artixcd his/hcr signaturc in thc spacc providcd ahovc on this ____
day of
I')
NOTARY PUBLIC
My Commission Expires:
FORM PUR 70(,8 (Rcv 0(,/05/91)
SWORN STATEMENT PIJRSIJANT TO SECTION 287.133(3)(a),
FLORIDA STATUTES, ON PIIBUC ENTITY CRIMES
THIS FORM MlJST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PlJBUC OR OTHER OFFICIAL
AIITHORIZED TO ADMINISTER OATHS.
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
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
statement:( .)
2. 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 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( I )(b), Florida Statutes, means a finding of guilt or a
conviction ofa 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 I, 1989, as a result of ajury verdict, non-jury trial, or entry of a plea of guilty or nolo
contendere.
4. 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 entity and who has been convicted of a public
entity crime, The term "affiliate" includes those officer, 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 ha~
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( 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 ofan entity.
6. Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted of a public entity crime subsequent to July I, 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 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, shareholdcrs,
employees members, or agent.s who are active in the management of the entity, or an affiliate of the entity has heen chargcd
with and convicted of a public entity crime subsequent to July I, 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 hy thc
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 I '\IH:RST\'\/l 'III\T TilE SIIJ\IISSIO'\ OF TillS FOR" TO IIIE COYIRHTI'\G OFFICER FOR Till PI BII( 1'\ III \
IIHSIHIUll'\ P\R\(;R\I'II I (O'\E) .\HOVE IS FOR TII\T PIHIIC I'\TITY O'\I.Y\'\Il. III \T TIllS H)I{\1 IS \.\111>
IIIROI(;IIIHTDIBER 31 OF Till C\I.E'\IHR YE\R 1'\ WIIJCIIIT IS FlI.EIl, I \I.S0 1''\/lERST\'\!l TII.\T I .\ \I RH)\ IIUIl
10 I'\HlR\I TIlE prill,/( IYITIT PRIOR TO E'\TERI'\G I'\TO .\ (O'\TR\CT 1'\ EXCESS OF TilE TIIRESIIOIIl .\\101 '\\
PRO\IIH:I) 1'\ SHIIO'\ 2117,017, !'-ORm\ ST\Tln:s FOR C\n:GORY TWO OF .\\Y (l1\'\(,E 1\ TIlE I'\HlH.\I.\TIO\
(O'\T\I'\EIlI'\ TillS FOR\!,
(Signature)
( I)alr)
sun: (H
(01'\ n OF
l'ERSO'-lAI.LY APPEARED BEFORE ME, thc undcrsigncd authority, _____________n.___
\\11\1.
allcr lirst hcing s\\orn hy mc, anixcd his/hcr signaturc in thc spaec provided ahovc on this ___.-._____ day of
I')
NOTARY PUBLIC
My Commission Fxpircs:
FORM PUR 70(,8 (Rev 0(,/0)/91)
SWORN STATEMENT PURSUANT TO SECTION 287.I3J(J)(a).
FLORIDA STATUTES. ON PlIBLlC ENTITY CRIMES
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PIJBLlC OR OTHER OFFICIAL
AIITHORIZED TO ADMINISTER OATHS,
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
and (if applicable) its Federal Employer Identification Number (FEIN) is
(If the entity has no FEIN,
statement:(
include the Social Security Number of the individual signing this sworn
)
2. I understand that a "public entity crime" as defined in Paragraph 287.133( I )(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( I )(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 ajury verdict, non-jury trial, or entry of a plea of guilty or nolo
contendere.
4. 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 entity and who has been convicted of a puhlic
entity crime. The term "affiliate" includes those officer, 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.
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 ofan entity.
6. Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted of a public entity crime subsequent to July I, 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 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 I, 1989.
The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholdcrs,
employees members, or agent.s who are active in the management of the entity, or an affiliate of the entity has heen charged
with and convicted of a public entity crime subsequent to July I, 1989. However, there has been a subsequent proceeding
before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Ordcr entered hy the
Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statcment 011 the
convicted vendor list. (attach a copy of the final order)
I I \IHRST\'\D TIIU TilE SIH.\IISSIO'\ OF TIllS FOR\I TO I(n: CO,\TR,\CI('\(; OHI(ER HlR TilE PlIlII( E'\ III \
IIHSI nlED 1\ P.\R\(;R\PII I (O'\F) .\IlOVE IS FOR TII\T I'IIII.IC E'\Tln O'\U\,\I), TII U TillS HlR\I IS \ \I III
IIIROl(;IIIHTDIBER 31 OF TilE C\I.E'\IHR 'E.\R 1'\ WIIICII IT IS FILED, I .\I.S0 1,\I)ERST.\'\D III.U 1.\ \I RH)IIRUl
(() I\FOR\I TilE I'lHI.I( E'\Tln PRIOR TO E'\TERI'\G I'\TO.\ CO'\TR\CT 1'\ EXCESS OF TilE TIIRESIIOI.D .\\I0l \1
PRO\IIHD 1'\ SHTIO'\ 2117.fl17, FLORID\ ST.\T1n:s FOR c\n:(;OR' TWO OF .\'\Y ClI\\(,E 1'\ TilE 1'\1-0R\I.\ 1(0\
(O'\T\I'\ED 1'\ TillS FOR\I,
(Signature)
ST\n: (H
(Date)
(01'\ I' OF
l'ERSO'-l.\I.LY AI'PL\REIlBEFORE \IE, thc undcrsigncd authority, ___m._m
. v..l1(\
aller lirst heing morn hy mc, affixcd his/hcr signaturc in thc spacc provided aho"c on this
day of
1'1
My Commission Expires:
NOTARY PUBLIC
FORM Pl!R 7068 (Rev 0('/OS/91)
I I '\IlERST\'\IlIIIU TilE SIH'IISSIO'\ OF TillS FOR'I TO IIIE CO'\TR\( 1('\(; OHICER FORIIIE PI 1l1I( E'd II \
IIHSIII-IEIl 1'\ I'\RH;R.\I'II I (O'\F) .\HOVE IS FOR TlIU r[HUC E'\Tln 0'\1.\ .\'\Il, TlIU TillS FOR\I IS \.\UIl
IIIRO((;IIIlUE\lHER 31 OF TIlE C\IE'\IHR n:,\R 1'\ WIIIClIIT IS m.EIl, I \ISO I'\I)ERST\\!) TIIU 1\ \I RH)11R11l
10 I'\HlR\I TilE I'IIIU( E'\TIT\ PRIOR TO E"TERI'\G I\TO A CO'\IR\CT 1'\ EXCESS OF TilE TIIRESIIOI.Il .\\101 \1
PRO\IIlED 1'\ SHTIO'\ 2117.flI7, H.ORIIH ST,\T1n:s FOR c\n:(;OR\ TWO OF \'\Y C1L\\(;E 1'\ TIlE I'\FOR\LUIO\
(O'\T\I'\EIlI'\ TillS FOR'1.
(Signa lure)
(I)atc)
sun: 01'
(01 SIT OF
I'ERSO'\AIL\ APPEAR!]) HEFORE ME, the undcrsigncd authority,_~
, \\11(\
allcr lirsl hcing sworn hy mc, affixcd his/hcr signaturc in thc spacc prnvidcd ahovc on this__________
day 01'_
. I')
NOTARY PUBLIC
My Commission Expircs
FORM PUR 70(,8 (Rcv O('/())/91)
I I '\IH.RSI.\ '\Il TlI\T TIlE SIH\IISSIO'\ OF TillS FOH\! TO 1111: CO'\IR\C 11'\(; OHICEH FOR TIIF PI Illl( F'\ III \
IIHSIHIUl 1'\ P\R\(;R\I'II I (O'\E) .\HOVE IS FOH TlL\T plllI.IC E'\T1n 0'\1-' .\,\1), TlI\T TillS FOR\I IS \ \I III
IIIRO\(;IIIlHE\!HER 31 OF TilE C\I.E'\OAR YEAH 1'\ WIIIClIIT IS FII,EIl, I \LSO l'\IlERST\'\!l TlI\T 1\ \I HH)IIRLlI
10 I'\HlR\! TilE I'IHI.I( E'\TITY I'HIOR TO E'\TEHI'\G I'\TO \ COYIR\CT 1'\ EXCESS OF TIlE TIIHISIIOLIl.UIOI "I
PHO\'IIHIlI,\ SHTIO'\ 2117,fl17, FLOHIIl\ ST.\T\TES FOR C\n:(;OHY TWO OF A'\Y CII.\'\(;I 1'\ TilE I'\HlH\L\TlO'\
(O'\T\I'\Ul 1'\ TillS FOR\!,
(Signature)
ST\n: OF
(l)atr)
COI'\ n OF
PERSO:'iAI.I-' AI'PL\REIl HEFORE \IE, thc undcrsigncd authority,_.
. \\11(\
allcr lirst hcing s\\orn hy mc, aniscd his/hcr signaturc in thc spacc providcd ahove on this __________ day 01'.__
1'1
NOTARY PUBLIC
My Commission !'spircs'
FORM Pl!R 70(,8 (Rcv O('/OS/91)
SWORN STATEMENT PURSUANT TO SECTION 287.13J(J)(a),
FLORIDA STATUTES. ON PUBLIC ENTITY CRIMES
THIS FORM MIIST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PlIBLlC OR OTlIER OFFICIAL
AIITHORIZED TO ADMINISTER OATHS.
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
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
statement:( .)
2. I understand that a "public entity crime" as defined in Paragraph 287.133( I )(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 publ ic 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(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 ofajury verdict, non-jury trial, or entry ofa plea of guilty or nolo
contendere,
4. I understand that an "affiliate" as defined in Paragraph 287.133(1 )(a), Florida Statutes, means:
I. 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 officer, 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 ofa 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 appl ies 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 ofan entity.
6. Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted of a public entity crime subsequent to July I, 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 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 I, 1989.
The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholdcrs,
employees members, or agents who are active in the management of the entity, or an affil iate of the entity has heen chargcd
with and convicted of a public entity crime subsequent to July I, 1989. However, there has been a suhsequent proceeding
before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entcred hy thc
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 I 'o,IlERS 1.\ 'o,1l 1I1.\T IIIE SIIl'IISSIO'o, OF TIllS FOR\! TO IIn: CO'\IR\C 1('\(; OFFI(ER FOR IIIE PI.IIII( L'\ 111\
IIHSI IFlI:1l ''0, P\R\(;R\I'II I (O'\E) \BOVE IS FOR TII\T I'IIIIIC E'\TIn O'\I.Y\,\Il, TII\T TIllS FOR\! IS \.\1.1Il
I1IRO((;1I mTE\!IIER 31 OF TilE C\I.E'\IHR YEAR 1'\ WIIICIIIT IS FIIEI>. I \I.S0 l'\I>ERST\'\!l TII\T I A \I RH)IIHLI>
10 I\FOH\! TilL I'lBI.IC E'\TITY PHIOH TO E\TEHI'\G I'\TO.\ CO'\IR\CT 1'\ EXCESS OF TilL TIIHLSIIOLI> .\'101 \1
PHo\'II>LD 1\ SHTIO\ 2117,017, H.ORm.\ STATln:S FOR C\n:<;ORY TWO OF .\'\Y C11\\(.L 1'\ TilE l'\FOR\!.\lIO\
(O'\T\I\U) 1'\ TIllS FOH\!,
(Signature)
ST\n: OF
(l)ale)
(0( sn OF
PEHSO:'llALLY APPL\HEIl BEFORE 'IE, the undcrsigncd authority, ___________~ _ _______
\\hi1
allcr lirst hcing morn hy mc, aflixcd his/hcr signaturc in the spacc providcd ahovc on this __.______ day of.___
19
NOTARY PUBLIC
My Commission Expircs
FORM PUR 7068 (Rcv O('/OS/91)
SWORN STATEMENT PIJRSIIANT TO SECTION 287.IJJ(J)(a),
FLORIDA STATUTES, ON PlIBLlC ENTITY CRIMES
THIS FORM MIJST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PIIBLlC OR OTHER OFFICIAL
AUTHORIZED TO ADMINISTER OATHS.
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
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
statement: ( .)
2. ) understand that a "public entity crime" as defined in Paragraph 287. 133(I)(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 publ ic 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( I )(b), Florida Statutes. means a finding of guilt or a
conviction ofa 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 ajury verdict, non-jury trial, or entry of a plea of guilty or nolo
contendere.
4. I understand that an "affiliate" as defined in Paragraph 287,133(1 )(a), Florida Statutes, means:
I. 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 officer, 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 ofa 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. I 33(l)(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 ofan entity.
6. Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted of a public entity crime subsequent to July I, 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 the management of the entity, or an affiliate of the entity has heen chargcd
with and convicted of a public entity crime subsequent to July I. 1989.
The entity suhmitting this sworn statement, or one or more of its officers, directors, executives, partners, sharcholdcrs,
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 I, 1989. However, there has heen a subscquent proceeding
before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entercd hy the
Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statcment on thc
convicted vendor list. (attach a copy of the final order)
I 1 '\IH.RST\'\1l TII.\T TilE SIB\IISSIO'\ OF TillS FOR\! TO 1111: CO'\TR\( 11,\(; OHICFR I-OR TilE PI BI.I< 1-'\111 \
IIlE'\ IIHI-Il 1'\ P.\R\c;R\PII I (O'\F) \BO\E IS FOR TII\T PIBUC E'\TIT\ 0'\1' .\'\Il, '111\'1 TIllS HlR\I IS \.\UIl
IIIROI(;1I IlHDIIIER 31 OF TilE C\lE'\IHR 'T\R 1'\ WIIICIIIT IS FII.EIl, 1 .\LSO I'\IHRST\'\() 111.\'1 1\ \I HH)IIHFIl
10 I'\HlR\! TilE PIBU( E'\TIT\ PRIOR TO E'\TERI'\(; I'\TO \ (OYI R\CT 1'\ EXCESS OF TilE TIIRESIIOUl\\JOI '\1
PRO\'lIlEIlI'\ SECTlO'\ 2117.fl17, HORIIH SIXnn:s FOR C\n:(;OR\ TWO OF \'\\ CII\,\(;E 1'\ TilE I'\FOR\J.\T10'\
(O'\T\I'\EIlI'\ TIllS FOR\I,
(Signature)
ST\n: 01-
(Date)
(01'\ n OF
PERSO'-lAI.L\ \I'PEARED HI-FORE 'IE, the undcrsigncd authority, _..___
\\Ihl
allcr lirst b~ing s\\orn by m~, affix~d his/hcr signatur~ in th~ spa~~ provid~d abo\~ on this
day of
, I')
My Commission Expircs:
NOTARY PUBLIC
FORM PUR 70(,8 (Rcv 0('/OS/91)
SWORN STATEMENT PllRSIJANT TO SECTION 287.IJJ(J)(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.
This sworn statement is submitted to
by
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
and (if applicable) its Federal Employer Identification Number (FEIN) is
(If the entity has no FEIN,
statement:(
include the Social
.)
Security Number of the
individual
signing this sworn
2. I understand that a "public entity crime" as defined in Paragraph 287.133( I )(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. I33(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 I, 1989, as a result ofajury verdict, non-jury trial, or entry ofa plea of guilty or nolo
contendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133(1 )(a), Florida Statutes, means:
I. 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 ofa public
entity crime, The term "affiliate" includes those officer, 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
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 an entity.
6. Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the 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 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 I, 1989.
The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders,
employees members, or agent.s who are active in the management of the entity, or an affiliate of the entity has heen charged
with and convicted of a public entity crime subsequent to July I, 1989. However, there has heen a suhsequent proceeding
before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered hy the
Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on thc
convicted vendor list. (attach a copy of the final order)
I( \IlERST\'\IlIII\T IIIE SIIl\lISSIO'\ OF TIllS H)R\I TO 1111-: CO,\IR\CI('\(; OFFICER FOR TlH. PIIlU( 1\111\
IIHSIHIUl 1'\ P\R\<;R\I'II I (O'\E) .\IUl\E IS FOR TlI.\T rllll.lC L\TITY O\I.Y\,\Il, TlI\T III1S FOR\! IS \.\UIl
IIIRO((;IIIHTnIBER 31 OF TilE C\I.E'\Il.\R YEAR 1'\ WIIICIIIT IS FlLEI), I \I.S0 1',\IlERST.\\[) TII.\T I .\ 'I RH)IIIUIl
10 I'\HlR\I TilE 1'(1l1.l( E'\T1TY PRIOR TO ~SIERI'\G I'\TO \ COYIR\CT 1'\ EXCESS OF TilE TIIRESIIOI.Il .\\101 \1
PRO\IJ)U) 1'\ SECTlO'\ 2117,()17, HORIIH ST,\Tln:s FOR C\IU;ORY TWO OF .\'\Y C11.\'\(.E 1'\ TIlE I'\HlR\!\ 110\
(O'\T\I'\EIlI'\ TillS FOR\\.
(Signature)
ST.\ n: OF
(I>atr)
(OISI\ OF
PERSO'-lAI.LY APPEARED BEFORE !\IE,lhc undcrsigncd authority, ~____.
\\hl1
allcr first heing sworn hy mc, afli,cd his/hcr signaturc in thc spacc provided ahovc on this
day of
I')
NOTARY PUBLIC
My Commission I'xpircs
FORM PUR 70(,8 (Rcv ()('/OS/91)
SWORN STATEMENT PIJRSIJANT TO SECTION 287.I3J(J)(a),
FLORIDA STATUTES. ON PUBLIC ENTITY CRIMES
THIS FORM MIIST 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
hy
(print individual's name and title)
for
(print name of entity submitting sworn statement)
whose business address is
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
statement:<-- .)
2. 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 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( 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 I, 1989, as a result ofajury verdict, non-jury trial, or entry ofa plea of guilty or nolo
contendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133(1 )(a), Florida Statutes, means:
I. 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 officer, 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.
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 hid 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, memhers, and agents
who are active in management of an entity.
6, Based on information and belief, the statement which I have marked 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 its officers, directors, executives, partners, shareholders,
employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity have been
charged with and convicted of a public entity crime subsequent to July I, 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 the management of the entity, or an affiliate of the entity ha~ heen charged
with and convicted of a public entity crime subsequent to July I, 1989.
The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholdcrs,
employees members, or agents who are active in the management of the entity, or an affiliate of the entity has heen chargcd
with and convicted of a public entity crime subsequent to July I, 1989. However, there has been a suhscquent proceeding
before a Hearing Officer of the State of Florida, Division of Administrativc Hearings and the Final Order entercd hy thc
Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statemcnt on thc
convicted vendor list. (attach a copy of the final order)
I 1 '\IH.J{ST\ "llll.\I IIIE SIII\IISSJ(l:\ OF TIllS FOR\I TO nn: CO'\TR\C n:\(; OFFICER FOR IIIE PI BIll ~SIII\
IIHSIHIEIl 1:\ P\R\(;R\I'II I (O'\E) .\1I0\E IS FOH TlI.\I 1'llll.lC E'\TlTY O:\U\'\Il, TlI\I IIIIS '.OJ{\1 IS \.\lIll
IIIROI (;IIIlH E\!IIER 31 OF TilE C\I.E'\IHR \EAH 1'\ WIIIClIIT IS FII.U), I \I.S0 1''\llERST\'\ll III\T I .\\1 RH)I IRlll
10 I'\HlH\! TilE 1'1 II 1.1 ( E'\Tln PHIOR TO ~SIEHI'\G I'\TO.\ CO'\TR\CT 1'\ EXCESS OF TilE TIIHESIIOl.ll A\lOI \1
PHOVII)U) 1'\ SECTlO'\ 2117,()17, FI.ORIIH STAT! n:s FOH c\n:(;OH\ TWO OF \'\\ (l1\\(.E 1'\ TilE 1'\ FOR\!.\ 110\
CO\T.\I'\Ul 1\ TillS FOR\!,
(Signature)
(Date)
sun: OF
(01'\ IT OF
PERSO'-lAII.\ APPL\HEI) BEFOHE !\IE, thc undcrsigncd authority, __.
\\Ill.)
altcr lirst hcing s\\orn O} mc, afliscd his/hcr signature in the spacc providcd ahovc on this ____
day "I'
I')
NOTARY PUBLIC
My Commission Lxpircs:
FORM PUR 70(,8 (Rcv 06/05/91)