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• <br />40 <br />40 <br />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. 26 `fid <br />for 11AT, Elam Xer5- eto,.-., <br />2. This sworn statement is submitted by <br />(name of entity submitting swom Statement) <br />whose business address is 2-y/9 Lif-4,e l p- F7• A "-", F/ 3fc9VV <br />and applicable) its Federal Employer Identification Number (FEIN) is _Q7- <br />0 V6 75-1 <br />Q- <br />0V67.5-! 9 . (If the entity has no FEIN include the Social Security Number of <br />the individual signing this sworn statement: ) <br />3. My name is 3-0 X, w /n leC, (I., x and my <br />(please print name of individual signing) <br />relationship to the entity named above is, !Jf d e d/-1 <br />4. 1 understand that a "Public Entity Crime" as defined in Paragraph 287.133(1)(g), <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 E ntity <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 entity 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 />6. 1 understand that an "affiliate" as defined in Paragraph 287.133(1)(a),Florida <br />Statutes, 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 pubiic entity <br />crime. The term "affiliate" includes those officers, directors, executives, <br />partners, shareholders, employees, members, and agents who are active in <br />the management of an affiliate. The ownership by one person of shares <br />constituting a controlling interest in another person, or a pooling of <br />STATEMENT OF PUBLIC ENTITY CRIMES <br />3 - 1 <br />