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01111111 <br />11 <br />I <br />I <br />May 25, 1999 <br />I UNDERSTAND THAT THE SUBMISSION OF'rms FORM TO THECONTRACTING [OFFICER <br />FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAVII I (CINE) ABOVE IS FOR THAT PUBLIC <br />ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF Tilt:; <br />CALENDAR YEAR IN WHICIi IT IS FILED, I ALSO UNIII IISTAND 'TTIA7' I AM RI QUIRED "I'O <br />INFORM THE PUBLIC ENTITY PRIOR TO EN'T'ERING INTO A CONTRACT IN EXCESS OF TIIE <br />TEIRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA_ TATUTFIS FOR CATEGORY <br />71VO OF ANY CHANGE INTHE INFORMATION CON'T'AINED IN THIS FORM. <br />[signature] <br />c <br />[date] <br />STATE OF F— <br />COUN'T'Y OF <br />PERSONALLY APPEARED BEFORE ME, lite undersigned authority, <br />Z �`} [name of individual signing] <br />who, after first being sworn by me, affixed ltislhcr signature in the space provided above on this 3 rc` <br />�• c <br />day of rl � _ 19 _ <br />r 7; <br />NOUTAIIY PUBLIC <br />My commission expires; <br />Form PUR 7068 (R€ v. 04110/91) <br />GRA01 V:&ffi <br />MYc0hfh11$S10N 1 cc 7P6017 <br />,axa EftPlFii:"u:iktaLer26.2002 <br />R -*d rm, ]tarn <br />ryrlhn;IMr7tirra,r, <br />PEC -3 <br />