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1 -1 <br />40 <br />0 <br />0 <br />0 <br />� STATEh8ENTDFPUBL|��ENTITY CR|K82S <br />� <br />This form is m sworn statement under Section 287.133(3)(o) Florida on public entity <br />crimes and must be signed in the presence of m notary public or other officer ��^�^"^'ou|horbed /' <br />administer oaths. <br />1This sworn statement |asubmitted with Bid. Proposal cvCon�nctNo� i� for i- <br />� <br />2. This sworn statement |osubmitted by ---------r <br />whose business address is T <br />VA <br />applicable) its Federal Employer <br />Identification Number (FEIN) is (ci )(if the entity has no FEIN. include the <br />Social Security Number of the individual signing this sworn statement- <br />- —/ name .~ <br />!| <br />and myrelationship (othe entity named above <br />i <br />� — 4. <br />|undershandd1ota^Pub|inGnh(yCdnm"madefinmdUl9armgnaph287�.�1`33(1)(g�) Eko-Lid—aStatutes, means a violation of any State or Federal law by a person with respect to and <br />LAdirectly related tothe transaction ofbusiness with any public entity orwith mnagency orU political subdivision of any other State or with [tie United 8ks(os, including, buil not limited any bid or contract for goods orservices to be provided to any /hz entity or an <br />agency or political subdivision of any other oiabo or of the United States and involving fraud, theft, bribery, collusion, racketeering, conspiracy, o/ _aH*no) <br />Amisrepresentation, <br />N N�� �I understand that "convicted" or "conviction" as defined /n PgneOnyph 288133(1)(b). <br />Elorida 8���U 'meonmoUndin0ufguUtoracunv/u\ionoyapub|ioenUtyodme with or <br />---�" without an adjudication of guilt, in any Federal or State �a| court ofrecord relating to <br />charges brought by indictment or information after July 1, 1889. as e result of e/ury <br />0X verdict, nonjury trio|, or entry of plea of guilty or nolo contendere. <br />6. | understand that an 'affiliate" as defined in Paragraph 287.133(i)(a). <br />0���� <br />means: . <br />— a. A predecessor orsuccessor ofo person convicted of public entity crime; or, <br />b� Anentity under the control of anatural person who ioactive inthe monmQn'antoy <br />L4 the enUtyand who has been convicted ofopublic enh\ycrime. The term "-''i|i <br />—' m(e^ <br />officers, em--'emo <br />members. and oQon(o who are active in the management of an '0|i`-'�The <br />L4 ownership by one person of shares constituting a controlling interest in another <br />peroon, ora pooling ofequipment orincome among persons when not for fair <br />market va;ue under an arm's length agreement, shall be a prima facie case that one <br />