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RWe 14.24MI FA.Q STATE OF FLORIDA DEPARTMENT OFTRAN5PORTATIO14 700450.21 <br />Rule 14-7e,008FA.C. CONTRACTOR'S AFFIDAVIT AND SURETY CONSENT 110T72!ON <br />08M9 <br />(FORM 21-A) Page / a2 <br />STATE OF FLORIDA <br />COUNTY OF . .L1.0o(_0 . <br />Before me, the undersignJd Notary Public, personally appeared Charles D. Kerns <br />to me well known)r who has produced as identification, <br />(Type of Identification) <br />who being first duly sworn, deposes and says that he/she is: President <br />(Title of duly authorized person) <br />of Kerns Construction and Property Mgmnt Corp. a CoWration <br />(Contracting entity) (Type of entity) <br />the Contractor on Financial Project I.D. 4317281-68.01 Road No. in <br />Indian River County, Florida under Contract No. <br />with the State of Florida Department of Transportation dated the day of <br />and that the Affiant based on his/her personal knowledge says that: <br />1. Said contract has been compiled with in every particular by the Contractor and that all parts of the work have been approved <br />by the District Director of Operations of the State of Florida Department of Transportation. <br />2. The Contractor has not offered or made any gift or gratuity to, or made any financial transaction of any nature with, any <br />employee of the Department In connection with obtaining or performing said contract <br />3. All amounts payable for labor, materials, or otherwise, in connection with said contract and work have been paid except for <br />normal sub -contract retainages, which will be satisfied within 30 days after payment and/or release of retainage withheld under said <br />contract <br />4. There are no claims or sults pending against sold Contractor or anyone In connection with the work done, materials furnished <br />or otherwise, under said contract except as listed below. As to any such exception listed below, the Contractor has stated the name of <br />the entity making the claim, the name of the entity against whom the claim is being made, and demonstrated below good cause as <br />required by Section 337.11 (11), Florida Statutes. <br />Claiming Entity Claim Agent Nature of claim Good cause explanation <br />State of Florid <br />County ofLue'Le _ <br />Sworn to and subscribed before me this _ a36 day <br />e (Print name of person signing Affidavit) <br />CiQrnnitS3JOFl �tplres•- <br />Pemh.a6 Known .X OR Produced Identification <br />Type ofidentificbtion Produced <br />JWA J. Guffmrx <br />MY COW41SSION 8 FF92160T <br />EXPIRES Oclobw 31 2019 <br />4or '9164t5,1 F .air <br />A false statement or omission made in connection with this affidavit is <br />sufficient cause for suspension, revocation, or denial of qualification to bid, <br />and a determination of non-responsibiiily, and may subject the person and/or <br />entity making the false statement to any and all civil and criminal penalties <br />available pursuant to applicable Federal and State Law. <br />Kerns Coat tructifln and Property Mgmnt. Corn. <br />ntractor <br />— IC By <br />Charles D. Kerns, President <br />Title <br />P99 <br />