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PUBLIC ENTITY CRIME FORM <br />SWORN STATEMENT UNDER SECTION 287.133(3) (a), FLORIDA STATUTES ON <br />PUBLIC ENTITY CRIMES <br />THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A <br />NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER <br />OATHS. <br />1. This sworn statement is submitted to Indian River County, FL b- <br />Dalas Lamberson Vice President <br />(print individual's name and title) <br />for <br />name of entity submitting sworn statement) <br />-whose business address is <br />2719 17`x' St. E.. Palmetto. FL 34221 <br />and (if applicable its Federal Employer Identification Number (FEIN) is <br />59-2513308 <br />2. 1 understand that a "public entity crime" as defined in Para. 287.133(i)(g), Florida <br />Statutes, means a violation of any state or federal law by a person with respect to <br />and directly related to the transaction of business with any public entity or with an <br />agency or political subdivision of any other state or with the United States, <br />including, but not limited to, any bid or contract for goods or services to be <br />provided to any public entity or an agency or political subdivision of any other <br />state or of the United States and involving antitrust, fraud, theft, bribery, <br />collusion, racketeering, conspiracy, or material misrepresentation. <br />I understand that "convicted" or "conviction" as defined in Para. 287.133(1)(b), <br />Florida Statutes means a finding of guilt or a conviction of a public entity crime, <br />with or without an adjudication of.guilt, in any federal or state trial court of record <br />relating to charges brought by indictment of information after July 1, 1989, as a <br />result of a jury verdict, non! -jury trial, or entry of a plea of guilty or nolo <br />contendere. <br />4. 1 understand that an "affiliate as defined in Para. 287.133(1)(a), Florida Statutes <br />means; <br />184 <br />