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SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a) FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS. 1 . This sworn statement is submitted to QLT\/ of ~ U.V\f\\.} \ ~\P-<~ ~ea.c.--h -t:-h by ,-) f)-VV\S-S-\:-i~~t:kl I J for C-LE A N ~N Ch --0'f? 'Trs~, l JJ(l:::; . . whose business address is l () 3.3n .N. W. 65 ..s-r ~ 1..< tJ R...1~e:) f- L ~3~f) I and (if applicable) its Federal Employer Identification Number (FEIN) is 1~5 - (J 7 b 1..[ 7-73 (IF the entity had no FEIN, include the Social Security Number of the individual signing this sworn statement: 2. 1 understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means 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 or with an agency or political subdivision of any 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 state or of the United States and im~olving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. . 3. 1 understand that "convicted" or "conviction" as defined in Paragraph 287.1 33(1)(b), Florida Statutes means 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 ofrecord 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 contenders. 4. I understand that an "affiliate" as defined in Paragraph 287. 133(1)(a), Florida Statutes, means: a. A predec~ssor or successor of a person convicted of a public entity crime; or b. An entity under the control ofany natural person who is active inthe management of the entity and who has been convicted of a public entity come. The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the . management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value. under an arm's length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. 5. I understand that a "person" as defined in Paragraph 287.133(l)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a bind' g contract and which bids or applies to bid on contracts for the provision of goods or services let by a u lic entity, or which otherwise transacts or applies to transact business with a public entity. The te m "person" includes those officers, directors, executives, partners, shareholders, employees, me s, and agents who are active in management of any entity. Signature ) Sworn to and subscribed before c:--_-4h1tr:s --f'/::5(1..jft:::1( who me IS this / It pers~nally p/;ti.oj day of dlECEIYJ.f5!l( 2004, by known to --IJl~ or. has provided las identification. Notary Seal: , ~ Tina G Kwiatkowski t~; MyCommiasion 00178568 ~ OI'''' Expires JanU8/Y 24. 2007 SIB I Request For Proposal Form