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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. I 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 with the 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 relation to the entity
<br /> ✓/ submitting this sworn statement. (Indicate which statement applies.)
<br /> Neither the entity submitting this sworn statement, nor any of it's officers, directors, executives, 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 subsequent 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 /> I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER 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 TO 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:C` � \��UNIIIIt \
<br /> (Signature) nn\d11 77
<br /> y�Yis`I-iF-0.- f fYi Ivok?un
<br /> (Printed1Name)
<br /> -PIT a-'
<br /> (Title)
<br /> 1 Sworn to and subscribed before me this 1 7 day of Rat' , 20 I b , by
<br /> Q,\-ws-1) A-c)1rinpRix n . I
<br /> (AFFIX . ,_ .JAMES 1 �� ` �
<br /> 1 b9:, Notary Public -State of Florida
<br /> My Comm.Expires Aug 17.2017 1 Signature: Notary Publi State of Florida
<br /> �; Commission M FF 013809
<br /> ' 4FrTJ°' Bonded Through National Notary Assn. (
<br /> Print or Type Commissioned Name
<br /> Personally Known •OR Produced Identification 1/
<br /> Type of Identification Produced CI Drida. aIf-Naos I ilpfl5e-
<br /> 1011998 313110
<br />
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