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4m <br />40 <br />O <br />G. Based on inibrimation and belief, lite statement which I have marked below is tore in relation to the entity <br />submitting this sworn statement. (Indicate ►Melt staletneut applies.) <br />Neither (lie entity submitting this sworn elulcnurit„ nor ally of its officers, directors, execulives, partners, <br />sl arebolders, employees, members, or agents wito are active in the management of the entity, nor any affiliate of the <br />entity has been charged with and convicted ofa public entity crime subsequent to July 1, 1989. <br />77ne entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, <br />shareholders, employees, members, or agents who are active in the nninagemcnt of the entity, or an affiliate of the <br />entity tins been charged with and convicted ofa public entity crime subsequent to July 1. 1989. <br />I'Itc entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, <br />shareholders, employees, members, or agents who are active in Clic management of the entity, or an affiliate of the <br />entity has been charged with and convicted ofa public entity crime subsequent to July 1, 1989. 1lowever, there ltas <br />been a subsequent Proceeding before a Hearing Officer of the :Sone of Florida, Division of Administrative Hearings <br />and the final Order entered by lite I lcaring Officer detennhted that it was not in the public interest to place the entity <br />submitting this swum statement on the convicted vendor list. (Attach a copy of the Final order.) <br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO TIIF CONTRACTING OFFICER FOR <br />THE PUBLIC EN'T'ITY IDENTIFIED IN AWHC'1.E I (ONE) ABOVE IS FOR 1.11AT PUBLIC ENTITY <br />ONLY AND, THAT THIS FORM IS VALID -111 ROUGH DECEMBER 31 OF THE CALENDAR YEAR IN <br />WHICH IT IS FILED. I ALSO UNDERSTAND'l'IlAT I AM REQUIRED TO INFORM THE PUBLIC <br />ENTITY PRIOR TO ENTERING INTO A CONTRACTIN EXCESS OF THE THRESHOLD AMOUNT <br />PROVIDED IN SECTION 297.017, FLORIDA STATIA-L FOR CATEGORY'r%VO OF ANY CHANGE IN <br />THE INFORMA'T'ION CONTAINED IN THIS FORM. <br />_9 <br />= _ - <br />(Signafure} <br />Sworn to and subscribed before nee this cday of d<'—,9?nc4� <br />Personally known 0 c �l _1 • x` <br />OR Produced idea itication Pj,3 "f �— <br />r') /. , <br />(Type of identification } <br />Fonn PUR 7068 (Rev. 06/1 1192) <br />Indiandverconlract4001.doc <br />Notary Public -State of <br />My commission expires <br />(Printed typed or st;ntgncd commissioned name <br />Of notaty public_) <br />Page 25 of 25 <br />Document last printed 05! 18100 10739 AIA <br />