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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 its officers, directors, executives, <br />partners, shareholders, employees, members, or agents who are active in the management of the entity, nor <br />any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July <br />1, 1989. <br />The entity submitting this sworn statement, or one or more of its officers, directors, executives, <br />' partners, shareholders, employees, members, or agents who are active in the management of the entity, nor <br />any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July <br />1, 1989. <br />The entity submitting this sworn statement, or one or more of its officers, directors, executives, <br />partners, shareholders, employees, members, or agents who are active in the management of the entity, nor <br />any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July <br />1, 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 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY <br />AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT <br />IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO <br />ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION <br />287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION <br />CONTAINED IN THIS FORM. <br />gnature] <br />Sworn to and subscribed before me this k (6 day of TJ n; E , 2044 <br />Personally known <br />OR Produced identification Notary Public - State of �i r�2 ('► <br />(Type of identification) My commission expires 00 cY <br />(Printed typed or stamped <br />commissioned name of notary public) <br />Form PUR 7068 (Rev. 06/11/92) 00402 -2 03 -4465 <br />