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market value under an arm's length agreement, shall be a prime facie case that one person
<br />controls another person. A person who knowingly enters into a joint venture, with a person who
<br />has been convicted of a public entity crime in Florida during the preceding 36 months shall be
<br />considered an affiliate.
<br />11.5. 1 understand that a "person" as defined in Para. 287.133(1)(e), Florida Statutes, means any natural
<br />person or entity organized under the laws of any state or of the United States with1the legal power to
<br />enter into a binding Contract and which Bids or applies to Bid on Contracts for the provision of goods or
<br />services let by a public entity, or which otherwise transacts or applies to transact business with a public
<br />entity. The term "persons" includes those officers, directors, executives, partners, shareholders,
<br />employees, members, and agents who are active in management of any entity.
<br />11.6. Based on information and belief, the statement which I have marked below is true in rlelation to the entity
<br />submitting this sworn statement. (indicate which statement applies.)
<br />v Neither the entity submitting this sworn statement, nor any of it's officers, directors, a ecutives, partners,
<br />shareholders, employees, members, or agents who are active in the management of the entity, nor any
<br />affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1,
<br />1989.
<br />The 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 management of the entity, or an
<br />affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1,
<br />1989.
<br />The 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 management of the entity, or an
<br />affiliate of the entity has been charged with and convicted of a public entity crime suklsequent to July 1,
<br />1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of
<br />Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer of the
<br />State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer
<br />determined that it was not in the public interest to place the entity submitting this sworn statement on the
<br />convicted vendor list. (Attach a copy of the final order.)
<br />UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING O FICER FOR THE
<br />PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND,
<br />THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED, I
<br />ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TOI ENTERING INTO
<br />A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA
<br />STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.
<br />By:
<br />(Signature) A
<br />dus Lo
<br />(Printed Name) U«,
<br />(Title)
<br />a I
<br />Sworn to and subscribed before me this �D day of o 2o`kL, by
<br />(AFFI ( ARY §- Ji
<br />f
<br />commission # GG 190241
<br />Expires March 28, 2022 I e:
<br />y'Eor ��� �udeG Thru BuapK Noary p�ryp� (A •
<br />Personally Knowny OR Produced Identification ,
<br />
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