HomeMy WebLinkAbout2000-171Exhibit "D"
SWORN S'rATI1*MENT PURSUANT r0 SECTION287.1330) (a)
FLORIDA STATUTES, ON PUBLIC EINTITY CRINIES
IIIIS FORM MUST BE SIGNED IN THE PRFSENCE OF A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED `f0 ADMINISTER OA'rns.
1. This sworn statement is submitted to, L s
�t (print namTofpublic ertiY
by Nr . 1 1 P 5 r r)p A
(print individual. name and title)
for 5t�—f�n
(print name of entity Subnti�iItfn- vrrnt statement)
whose business address is ' �sa �d est I. n n L0 A q-- -
and (if applicable) its Federal Employer Identification Number (FEIN) is S el j/)& (If lite entity
has no FEIN, including lite Social Security Number of Ore individual signing this sworn slatement:
2. 1 understand that a "public entity crime" as defined in Parargraplt 287.133(i)(g), Florida Statutesmems a
violation of any state or federal law by a person vvilh respect to and directly related to the transaction of business
with any public entity or with an agency or political subdivision ofany other state or of the United States. including,
but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or
political subdivision of any other stale or of the United States and involving antitrust, fraud, Ilick, bribery collusion.
racketeering, conspiracy, or maicrial misrepresentation.
3. 1 understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes, means a
finding of guilt or a conviction of a public entity crintc, with or without an adjudication ol'guilt, ill any federal or
stare trial court of record relating to charges brought by indictment or illibrolation after July 1, 1999- as a result of a
jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.
4. 1 understand that an "affiliate" as defined in Paragraph 287,133(1)(a), Florida Stalutes, nleanx:
a. A predecessor or successor ora person convicted of a public entity critic: or
b. An entity under [lie control cif any natural person who is convicted of a public Clotty Clinic, The terns
affiliate" includes tltosc officers, directors, exectulivcs, partner~ sha,rcholcicrs, employces, members, and agents
Who are active in site management of an affiliate. The ownership by one person of shares constituting :t
controlling interest in another person, or a pooling of cq uipnaenl or income anuung persons when not ror fair
market value under an arm"s length agreentenl, shall be a prima facie case thm one person conlrols another
person. A person who knowingly enters into a joint venture will, it person Who ba+ been convicted ora public
entity crime in Florida during lite preceding 36 months shall be considered an affiliate.
5. 1 understand that a person as defined it, Paragraph 287.133 (1)(c), l la.titalutes means any natural person or entity
organized under [lie laws or any stale ur of the United Stales will, Ilse lq!;,) power te, enter into at binding contract
and which bids or applies to bid on contracts lindie provision of golds ur services let by a public entity, or which
other- wise transacts or appiics to transact business with a public entity. I luc tonal 'Dir on" includes those officers,
dirWors, Cx.CCUlr.vcs, parlr,et's, Alla lcholdvrs, croploym,,, members, and agenls who are active rr1 It liartatt4 ttlenl l'�l fin
entity.
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G. Based on inibrimation and belief, lite statement which I have marked below is tore in relation to the entity
submitting this sworn statement. (Indicate ►Melt staletneut applies.)
Neither (lie entity submitting this sworn elulcnurit„ nor ally of its officers, directors, execulives, partners,
sl arebolders, employees, members, or agents wito are active in the management of the entity, nor any affiliate of the
entity has been charged with and convicted ofa public entity crime subsequent to July 1, 1989.
77ne entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
shareholders, employees, members, or agents who are active in the nninagemcnt of the entity, or an affiliate of the
entity tins been charged with and convicted ofa public entity crime subsequent to July 1. 1989.
I'Itc entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
shareholders, employees, members, or agents who are active in Clic management of the entity, or an affiliate of the
entity has been charged with and convicted ofa public entity crime subsequent to July 1, 1989. 1lowever, there ltas
been a subsequent Proceeding before a Hearing Officer of the :Sone of Florida, Division of Administrative Hearings
and the final Order entered by lite I lcaring Officer detennhted that it was not in the public interest to place the entity
submitting this swum statement on the convicted vendor list. (Attach a copy of the Final order.)
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO TIIF CONTRACTING OFFICER FOR
THE PUBLIC EN'T'ITY IDENTIFIED IN AWHC'1.E I (ONE) ABOVE IS FOR 1.11AT PUBLIC ENTITY
ONLY AND, THAT THIS FORM IS VALID -111 ROUGH DECEMBER 31 OF THE CALENDAR YEAR IN
WHICH IT IS FILED. I ALSO UNDERSTAND'l'IlAT I AM REQUIRED TO INFORM THE PUBLIC
ENTITY PRIOR TO ENTERING INTO A CONTRACTIN EXCESS OF THE THRESHOLD AMOUNT
PROVIDED IN SECTION 297.017, FLORIDA STATIA-L FOR CATEGORY'r%VO OF ANY CHANGE IN
THE INFORMA'T'ION CONTAINED IN THIS FORM.
_9
= _ -
(Signafure}
Sworn to and subscribed before nee this cday of d<'—,9?nc4�
Personally known 0 c �l _1 • x`
OR Produced idea itication Pj,3 "f �—
r') /. ,
(Type of identification }
Fonn PUR 7068 (Rev. 06/1 1192)
Indiandverconlract4001.doc
Notary Public -State of
My commission expires
(Printed typed or st;ntgncd commissioned name
Of notaty public_)
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Document last printed 05! 18100 10739 AIA