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<br />181 ST ACTIVE PARK
<br />
<br />APRIL 10, 2005
<br />
<br />6. Based on information and belief, the statement which I have marked below is true in relation to the
<br />entity submitting this sworn statement. [Indicate which statement applies]
<br />
<br />~ Neither the entity submitting this sworn statement, nor any of its officers, directors,
<br />execfItives, partners, shareholders, employees, members, or agents who are active in the
<br />management of the entity, nor any affiliate of the entity has been charged with and convicted of a
<br />public entity crime subsequent to July I, 1989.
<br />
<br />The entity submitting this sworn statement, or one or more of its officers, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active in the
<br />management of the entity, nor any affiliate of the entity has been charged with and convicted of a
<br />public entity crime subsequent to July 1, 1989.
<br />
<br />The entity submitting this sworn statement, or one or more of its officers, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active in the
<br />management of the entity, nor any affiliate of the entity has been charged with and convicted of a
<br />public entity crime subsequent to July 1, 1989. However, there has been a subsequent proceeding
<br />before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final
<br />Order entered by the Hearing Officer of the State of Florida, Division of Administrative Hearings
<br />and the Final Order entered by the Hearing Officer determined that it was not in the public interest
<br />to place the entity submitting this sworn statement on the convicted vendor list. [attach a copy of
<br />the final order]
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER
<br />FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC
<br />ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE
<br />CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO
<br />INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE
<br />THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA ATUTES FOR
<br />CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CON NED IN S FORM.
<br />
<br />
<br />Sworn to and subscribed before me this f
<br />
<br />day of
<br />
<br />/ t/n-e-
<br />-/
<br />
<br />, 200 r-
<br />
<br />/' .1,7, I
<br />~ r'1 PrtJ/ I;'~ .
<br />
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<br />
<br />Not8.l)' Public - State of .IIf;;,,;.A
<br />
<br />Personally known
<br />OR Producedi.~~I1Hfi~~lion
<br />
<br />(Type of identification)
<br />
<br />,"'" i" DELI" L LEE
<br />~. ...., ..: ,',/ ~ MY COMMISSIOIH DD i54242
<br />, ~~,~, EXPIRES: October 19,2006
<br />.'., ~~ ,;-.I~: Bonder.! ThIll BIJ-igc\ Holary Services
<br />
<br />My commission expires /o'-/'1-ot
<br />
<br />(Printed typed or stamped
<br />commissioned name of notary public)
<br />
<br />Form PUR 7068 (Rev. 06/11/92)
<br />
<br />00402-2
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