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Exhibit "D"
<br />SWORN S'rATI1*MENT PURSUANT r0 SECTION287.1330) (a)
<br />FLORIDA STATUTES, ON PUBLIC EINTITY CRINIES
<br />IIIIS FORM MUST BE SIGNED IN THE PRFSENCE OF A NOTARY PUBLIC OR OTHER OFFICER
<br />AUTHORIZED `f0 ADMINISTER OA'rns.
<br />1. This sworn statement is submitted to, L s
<br />�t (print namTofpublic ertiY
<br />by Nr . 1 1 P 5 r r)p A
<br />(print individual. name and title)
<br />for 5t�—f�n
<br />(print name of entity Subnti�iItfn- vrrnt statement)
<br />whose business address is ' �sa �d est I. n n L0 A q-- -
<br />and (if applicable) its Federal Employer Identification Number (FEIN) is S el j/)& (If lite entity
<br />has no FEIN, including lite Social Security Number of Ore individual signing this sworn slatement:
<br />2. 1 understand that a "public entity crime" as defined in Parargraplt 287.133(i)(g), Florida Statutesmems a
<br />violation of any state or federal law by a person vvilh respect to and directly related to the transaction of business
<br />with any public entity or with an agency or political subdivision ofany other state or of the United States. including,
<br />but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or
<br />political subdivision of any other stale or of the United States and involving antitrust, fraud, Ilick, bribery collusion.
<br />racketeering, conspiracy, or maicrial misrepresentation.
<br />3. 1 understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes, means a
<br />finding of guilt or a conviction of a public entity crintc, with or without an adjudication ol'guilt, ill any federal or
<br />stare trial court of record relating to charges brought by indictment or illibrolation after July 1, 1999- as a result of a
<br />jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.
<br />4. 1 understand that an "affiliate" as defined in Paragraph 287,133(1)(a), Florida Stalutes, nleanx:
<br />a. A predecessor or successor ora person convicted of a public entity critic: or
<br />b. An entity under [lie control cif any natural person who is convicted of a public Clotty Clinic, The terns
<br />affiliate" includes tltosc officers, directors, exectulivcs, partner~ sha,rcholcicrs, employces, members, and agents
<br />Who are active in site management of an affiliate. The ownership by one person of shares constituting :t
<br />controlling interest in another person, or a pooling of cq uipnaenl or income anuung persons when not ror fair
<br />market value under an arm"s length agreentenl, shall be a prima facie case thm one person conlrols another
<br />person. A person who knowingly enters into a joint venture will, it person Who ba+ been convicted ora public
<br />entity crime in Florida during lite preceding 36 months shall be considered an affiliate.
<br />5. 1 understand that a person as defined it, Paragraph 287.133 (1)(c), l la.titalutes means any natural person or entity
<br />organized under [lie laws or any stale ur of the United Stales will, Ilse lq!;,) power te, enter into at binding contract
<br />and which bids or applies to bid on contracts lindie provision of golds ur services let by a public entity, or which
<br />other- wise transacts or appiics to transact business with a public entity. I luc tonal 'Dir on" includes those officers,
<br />dirWors, Cx.CCUlr.vcs, parlr,et's, Alla lcholdvrs, croploym,,, members, and agenls who are active rr1 It liartatt4 ttlenl l'�l fin
<br />entity.
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<br />Document Iasi printed 0511W00 10`3?Abs
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