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SWORN STATEMENT UNDER SECTION 287 . 133(3) (a) FLORIDA STATUTES , <br /> ON PUBLIC ENTITY CRIMES <br /> (To be signed in the presence of a notary public or other officer authorized to administer oaths . ) <br /> STATE OF Florida <br /> COUNTY OF Polk <br /> Before me , the undersigned authority , personally appeared Jason Chambers , who , <br /> being by me first duly sworn , made the following statement : <br /> 1 . The business address of Tri - Sure Corporation <br /> (name of Bidder or Contractor) is P . 0 . Box 653 , Auburndale , F1 33823 <br /> 2 . My relationship to Tri - Sure Corporation <br /> (name of Bidder or Contractor) is vice President <br /> (relationship , such as sole proprietor, partner, president, vice president) . <br /> 3 . 1 understand that a public entity crime as defined in Section 287. 133 of <br /> Florida Statutes includes a violation of any state or federal law by a person with respect to and <br /> directly related to the transaction of business with any public entity in Florida or with an agency <br /> or political subdivision of any other state or with the United States , including , but not limited to , <br /> any Bid or Contract for goods or services to be provided to any public entity or such an agency <br /> or political subdivision and involving antitrust, fraud , theft , bribery, collusion , racketeering , <br /> conspiracy, or material misrepresentation . <br /> 4 . 1 understand that "convicted" or "conviction" is defined by the statute to <br /> mean a finding of guilt or a conviction of a public entity crime , with or without an adjudication of <br /> guilt, in any federal or state trial court of record relating to charges brought by indictment or <br /> information after July 1 , 1989 , as a result of a jury verdict, nonjury trial , or entry of a plea of guilty <br /> or nolo contendere . <br /> 5 . 1 understand that "affiliate" is defined by the statute to mean (1 ) a <br /> predecessor or successor of a person or a corporation convicted of a public entity crime, or (2) <br /> an entity under the control of any natural person who is active in the management of the entity <br /> and who has been convicted of a public entity crime , or (3) those officers , directors , executives , <br /> partners , shareholders , employees , members , and agents who are active in the management of <br /> an affiliate , or (4) a person or corporation who knowingly entered into a joint venture with a <br /> person who has been convicted of a public entity crime in Florida during the preceding 36 <br /> months . <br /> 6 . Neither the Bidder or Contractor nor any officer, director, executive , <br /> partner, shareholder, employee , member or agent who is active in the management of the <br /> Bidder or Contractor nor any affiliate of the Bidder or Contractor has been convicted of a public <br /> entity crime subsequent to July 1 , 1989. <br /> (Draw a line through Paragraph 6 if Paragraph 7 below applies) <br /> 00310 - 9 <br /> BNSpecifications100310 Bid Form .doc <br />