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STATEMENT OF PUBLIC ENTITY CRIMES <br />This form is a sworn statement under Section 287.133(3)(a), Florida Statutes, on <br />public entity crimes and must be signed in the presence of a notary public or other <br />officer authorized to administer oaths. <br />9. This sworn statement is submitted with Bid, Proposal or Contact No. <br />for SCr� ,�'101AL te' Y'60.T`95 <br />2. This sworn statement is submitted by0�qI', Qr -Ae <br />e d e 5 �c— <br />(narne of entity subm lling sworn statement) <br />whose business address is I iavvinr;,-,A Or, F . (�;e�F� i~t_ 3ygY4 <br />and applicable) its Federal Employer Identification Number (FEIN) is _ <br />(if the entity has no FEIN, include the Social Security Number of <br />the individual signing this sworn statement: ) <br />3. My name is AA and nfry <br />please print name or individual signing} <br />relationship to the entity named above is ("re ri d e n <br />4. 1 understand that a "Public Entity Crime" as defined in 'Paragraph 287.133(1 <br />Florida Statutes, means a violation of any State or Federal law by a person with <br />respect to and directly related to the transaction of business with any public entity <br />or with any agency or political subdivision of any other State or with the United <br />States, 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 state <br />or of the United States and involving antitrust, fraud, theft, bribery, collusion, <br />racketeering, conspiracy, or material misrepresentation. <br />5. 1 understand that "convicted" or "conviction" as defined in Paragraph 286.133(1)(b), <br />Florida Statutes, means a finding of guilt or a conviction of a public entily crime, with <br />or without an adjudication of guilt, in any Federal or State trial court of record <br />relating to charges brought by indictment or information after July 1, 1989, as a <br />result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere. <br />B. 1 understand that an "affiliate" as defined in Paragraph 287.133(1)(a),Florida <br />Statu es, means: <br />a. A predecessor or successor of a person convicted of a public entity crime; <br />or, <br />b. An entity under the control of a natural person who is active in the <br />management of the entity and who has been convicted of a public entity <br />crime. The term "affiliate" includes those officers, directors, executives, <br />partners, shareholders, employees, members, and agents who aro active in <br />the managenlerrt of an affiliate. Thu, ownership by one parson of shares <br />constituting a conti-ollirig interest in ;another persue, or a pooling of <br />�;MT'urlir rq r•URLIr irinify cltr►p r <br />S - i <br />