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SWORN STATEMENT PURSUANT TO SECTION 28].133(7)(./,
<br />F! OR IDA CTATI ITxS, ON PUBLIC ENTITY CRIMES
<br />THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OMER
<br />f OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
<br />- 1. This two s ant is submined to
<br />by =rl`_ Shc,�l rQ int nvme oPublk enlltYl
<br />j YA J MY1
<br />for thC1 —�. Iprl l,individyal's nanre vntl lillel
<br />e 1•tt ce+ Ankle 3.
<br />THE CONTRACT SLIM; The County will pay the Connector for performance of the Convect. subject to additions
<br />and deductions previdedylerein, in current funds as follows:
<br />Numerical Amount
<br />i Wnnen Amowt I,(f,w•
<br />r I
<br />Fe ,sin ;•Qrf,dFa.r rr 7L-al.r G.`
<br />Ido;; v, lac, t
<br />'
<br />[print name of entity subm1111ng sworn sutemenQ
<br />whose business address is 1Y9/1 ZLI) ✓/in ✓/d,l 413✓,
<br />T1din.3
<br />and (if applicable) its Federal Employer Identification Number (FEIN) is
<br />(If We entity has no FEIN, include the Social Security Number of Ne individual signing this sworn statement:
<br />2. 1 understand Nate "public entity gime" as defined N Paragraph 287.133(I)(g), pier da.c at ne=, means a violation
<br />Of any sum orRdeul law by. person with respect to and directly aimed to the transaction ofbusiness with any
<br />public unity or with an agency or political subdivision of any .,her state or of the United States, including. but nm
<br />limited m, any bid or canard far goods or services in be provided to any public entity or an agency or political
<br />subdivision of any other state or of the United States and involving minimal, fraud, Rich, bribee, collusion,
<br />racketeering, conspiracy, or material mlarepreaemmion.
<br />J. 1 understand that "convicted" or "conviction" as distinct in Paragraph 287.133(1 Ula), plasma suntan, means a
<br />Bribing ofguilt or dwnviction of a public entity crime, with or without an adjudication of guilt, in any federal or
<br />auto final coon of record relating to charges brought by indictment or information after July I, 1989, as a result of a
<br />jury verdin, nonjusy teal, or entry of a plea ofguilty or nolo contendere.
<br />n. l understand that an" affiliate'aa defined in Paraguph 287.133(1)(.). Mild, ctamtae, means:
<br />I. A predecessor or successor ofa person convicted ofa public entity crime; or
<br />2. An entity under the control ofany natural person who is actne in the management of the entity and who has
<br />been convicted ofa public entity cruse. The term %filliate" includes those officers, directors, executives, palmers.
<br />sh... holder,, employees, members, and agents who are active in the manngemwt of an afliltate. The ownership by
<br />one person ofshares constituting a controlling Intorcst in another p......... pooling oFiximpmem or income
<br />among persons when not for fou market value under an amts length agreement, shall be a puna facie case that one
<br />person commis number person. A person who knowingly enters into ajohn venmm with a person who has been
<br />convicted of a public entity crime in Florida during the preceding 36 months shall be considered an afRlime.
<br />5. 1undersund that a"person" as defined in Paragraph 287.1331U(el.nn.laSan' e., means any natural pnson or
<br />entity organized under thc laws ofany state or of the United States with the legal power to enterinto a binding
<br />contract and which bids or applies to bid on contracts for the provision ofgoods or services let by a public entity, Or
<br />which otherwise transacts or applies to transect business with a public entity. The term "person" includes those
<br />officers, directors. executives, pmners, shareholders, employees, members, and agents who am native in
<br />PEC -2
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