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SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a),
<br />FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
<br />THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR
<br />OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
<br />i1. This sworn statement is submitted to C I I-/ QC S0-31,3q
<br />[pppt name of the public entity]
<br />by '`OSS ►2ANi,•cD V (LEsIDC -Mi
<br />' [print individual's name and title]
<br />for - 2 i r iZ7 A � �c� •
<br />[print name of entity submitting sworn statement]
<br />' whose business address is
<br />C1 (0 (0 � C) a:-af wE5 t ►4
<br />' C--o►ZT LAODEeDALG -hLo 2► 0n -,-�3"' ��
<br />and (if applicable) its Federal Employer Identification Number (FEIN) is 5 Ll (v og Z
<br />' (If the entity has no FEIN, include the Social Security Number of the individual signing this sworn
<br />statement: )
<br />2. I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a
<br />violation of any state or federal law by a person with respect to and directly related to the transaction of
<br />business with any public entity or with an agency or political subdivision of any other state or of the United
<br />States, including, but not limited to, any bid or contract for goods or services to be provided to any public
<br />entity or an agency or political subdivision of any other state or of the United States and involving
<br />antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.
<br />3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statues,
<br />means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in
<br />any federal or state trial court of record relating to charges brought by indictment or information after July
<br />' 1, 1989, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.
<br />4. I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes, means:
<br />1. A predecessor or successor of a person convicted of a public entity crime; or
<br />2. An entity under the control of any natural person who is active in the management of the entity and who
<br />has been convicted of a public entity crime. The term "affiliate" includes those officers, directors,
<br />' executives, partners, shareholders, employees, members, and agents who are active in the management of
<br />an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or
<br />a pooling of equipment or income among persons when not for fair market value under an arm's length
<br />agreement, shall be a prima facie case that one person controls another person. A person who knowingly
<br />enters into a joint venture with a person who has been convicted of a public entity crime in Florida during
<br />the preceding 36 months shall be considered an affiliate.
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<br />I understand that a "person" as defined in Paragraph 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 enter
<br />into a binding contract and which bids or applies to bid on contracts for the provision of goods or services
<br />let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The
<br />term "person" includes those officers, directors, executives, partners, shareholders, employees, members,
<br />and agents who are active in management of an entity.
<br />Form PUR 7068 (Rev. 06/11/92) 00402 -1
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<br />03 -4465
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