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SWORN-"STATEMENT UNDER SECTION 287 . 133 (3)(a ) FLORIDA STATUTES , ON PUBLIC ENTITY CRIMES (To be signed in the presence of a notary public or other officer authorized to administer oaths . ) STATE OF rloalCIO, COUNTY OF X-080c, 61 \*(_ee Before me , the undersigned authority, personally appeared G , who , being by me first duly swom , made the following statement: 1 . The business address of I SIpo SW mx) Owl (name of Bidder or Contractor) is 2 . My relationship to 1"tr,nnij, u (name of Bidder or Contractor) is *Tresi Cho 4 (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 . 4 . 1 understand that "convicted" or "conviction " is defined by the statute to mean 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 a jury verdict, nonjury trial , or entry of a plea of guilty or nolo contendere . 5 . 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 . 6 . Neither the Bidder or Contractor nor any officer, director, executive , partner, shareholder, employee , member or agent who is active in the management of the Bidder or Contractor nor any affiliate of the Bidder or Contractor has been convicted of a public 00310 - 9 F:\UtllitleMUTILITY - ENGINEERINGIWTP - North ROW RO Brine Une Discharge - UCP#22081BID DOCUMENTS North County ROXBID DOCUMENTS100310 Bid Form.doc