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181sT ACTIVE PARK APRIL 10, 2005
<br />SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(x),
<br />FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
<br />THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC
<br />OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
<br />1. This sworn statement is submitted to c: l Y U t s c ti N Y r� f roc r t
<br />[print name of the public entity]
<br />by /�,4 , " i--
<br />[print individual's name and title]
<br />for r t`
<br />[print name of entity submitting sworn statement]
<br />whose business address is
<br />L1000 %-10zLiwn ,0II oLt)p - 'TF t,2f') nJ
<br />L
<br />and (if applicable) its Federal Employer Identification Number (FEIN) is `0- -- i S lZE2s
<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,
<br />means a violation of any state or federal law by a person with respect to and directly related to the
<br />transaction of business with any public entity or with an agency or political subdivision of any
<br />other state or of the United States, including, but not limited to, any bid or contract for goods or
<br />services to be provided to any public entity or an agency or political subdivision of any other state
<br />or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering,
<br />conspiracy, or material misrepresentation.
<br />3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida
<br />Statues, means a finding of guilt or a conviction of a public entity crime, with or without an
<br />adjudication of guilt, in any federal or state trial court of record relating to charges brought by
<br />indictment or information after July 1, 1989, as a result of a jury verdict, nonjury trial, or entry of a
<br />plea of guilty or nolo contendere.
<br />4. 1 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
<br />and who has been convicted of a public entity crime. The term "affiliate" includes those officers,
<br />directors, executives, partners, shareholders, employees, members, and agents who are active in
<br />the management of an affiliate. The ownership by one person of shares constituting a controlling
<br />interest in another person, or a pooling of equipment or income among persons when not for fair
<br />market value under an arm's length agreement, shall be a prima facie case that one person controls
<br />another person. A person who knowingly enters into a joint venture with a person who has been
<br />convicted of a public entity crime in Florida during the preceding 36 months shall be considered
<br />an affiliate.
<br />5. I understand that a "person" as defined in Paragraph 287.133(lXe), Florida Statutes, means any
<br />natural person or entity organized under the laws of any state or of the United States with the legal
<br />power to enter into a binding contract and which bids or applies to bid on contracts for the
<br />provision of goods or services let by a public entity, or which otherwise transacts or applies to
<br />transact business with a public entity. The term "person" includes those officers, directors,
<br />executives, partners, shareholders, employees, members, and agents who are active in management
<br />of an entity.
<br />Form PUR 7068 (Rev. 06/11/92) 00402 -1
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