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i dw 40 SWORN STATEMENT UNDER SECTION 297.133(3)(a) FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES r. (To be signed in the presence of a notary public or other officer authorized to administer oaths.) STATE OF Florida lfl�hil11�4•�s35 Before me, the undersigned authority, personalty appeared .tames lt. Chambers , who, being by me first duly sworn, made the following statement: 1. The business address of Tri -Sure Corporation (name of Bidder orContractor)is P. 0. Box 653 Auburndale F1 33823 2. My relationship to Tri -Sure Corporation (name of Bidder or Contractor) is President (relationship, such as sole proprietor, partner, president, vice president). 3. 1 understand that a public entity crime as defined in Section 287.133 of Florida Statutes includes a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity in Florida or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any Bid or Contract for goods or services to be provided to any public entity or such an agency or political subdivision and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 44. 1 understand that "convicted" or "conviction" is defined by the statute to wean a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of ajury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere. S. 1 understand that "affiliate" is defined by the statute to mean (1) a predecessor or successor of a person or a corporation convicted of a public entity crime, or (2) an entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime, or (3) those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate, or (4) a person or corporation who knowingly entered into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months.. i " 00310-24 S WORN STATEM EN T I C:vn ;Khfohvwn Figttuv} tQjed- RnCPridv sewer lnq,ro,erroemsWh}IO.doc