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<br />6. Based on information and belief, the statement which I have marked below is true in a <br />relation to the entity submitting this sworn statement. (Please indicate which one (1) of the <br />following three (3) statements is applicable.) <br /> <br />_ (1) Neither the entity submitting this sworn statement, nor any of its officers, directors, <br />executives, partners, shareholders, employees, members, or agents who are active in the <br />management of the entity, or any affiliate of the entity has been charged with and convicted of <br />a public entity crime within the past 36 months. <br /> <br />_(2) 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, or any affiliate of the entity has been charged with and convicted of <br />a public entity crime within the past 36 months. <br /> <br />_(3) 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, or agents who are active in management of the entity, or any affiliate <br />of the entity has been charged with and convicted of a public entity crime within the past 36 <br />months. However, there has been a subsequent proceeding before a Hearing Officers of the <br />State of Florida, Division of Administrative Hearings and the Final Order by the Hearing <br />Officer determined that it was not in the public interest to place the entity submitting this sworn <br />statement on the convicted vendor list. (Attached is a copy of the final order.) <br /> <br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING <br />OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS <br />FOR THE PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH <br />DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED AND FOR THE <br />PERIOD OF THE CONTRACT ENTERED INTO, WHICHEVER PERIOD IS LONGER. I <br />ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY <br />PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD <br />AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR THE <br />CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS <br />FORM. <br /> <br />SIGNA TURE OF AFFIANT <br /> <br />(Printed or Typed Legal Name of Affiant) <br /> <br />State of County of <br />Sworn to and subscribed before me this <br /> <br />day of <br /> <br />,2010by <br /> <br />Notary Seal: <br /> <br />Notary's Name Printed, Stamped or Typed <br /> <br />Personally Known: <br /> <br />or Produced Identification <br /> <br />Identification Produced <br />