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<br />SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(11)
<br />FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
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<br />THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
<br />OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
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<br />l. This sworn statement is submitted to
<br />by ADI<-IALJA.. ~\.lt"""a -l-4IL~
<br />for tzf= 4> C> 7 - 0 ~ - D I eve;;. ~-vLv. '1:'(2.4 Oce
<br />whose business address is IZ'?45 ~,e:, b-li- Av~~, A, f{ota-( KIA:,tU, ~ ~3Ib\
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<br />and (if applicable) its Federal Employer Identification Number (FEIN) is irfi" t7+12-tv~ I
<br />(IF the entity had no FEIN, include the Social Security Number of the individual signing this sworn statement:
<br />!? '1'? - 24 -ol fdJeo
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<br />2. I understand that a "public entity crime" as defined in Paragraph 287. I 33(1)(g), Florida Statutes. means a violation of
<br />any state or federal law by a person with respect to and directly related to the transaction of business with any public
<br />entity or with an agency or political subdivision of any other st!lte or of the United States, including, but not limited to,
<br />any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any
<br />othcr state or of the United States and involving antitrust, fraud. theft, bribery, collusion, racketeering, conspiracy. or
<br />material misrepresentation,
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<br />3, I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes means a finding
<br />of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial
<br />cou11 of record relating to charges brought by indictment or information after July I, 1989, as a,result of a jury verdict,
<br />nonjury trial, or entry of a pica of guilty or nolo contenders.
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<br />4. I understand that an "affiliate" 8S defined in Paragraph 287,133(1)(a), Florida Statutes. means:
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<br />a. A predecessor or successor of a person convicted of a public entity crime; or
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<br />b. An entity under the control of any natural person who is active in the management of the entity and who has been
<br />convicted of a public entity come. The term "affiliate" includes those officers, directors, executives, partners.
<br />shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership
<br />by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income
<br />among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that
<br />one person controls another person. A person who knowingly enters into a joint venture with a person who has
<br />been convicted ofa public entity crime in Florida during the preceding 36 months shall be considered an affiliate,
<br />5, I understand that a "person" as defined in Paragraph 287. I 33(J)(e), Florida Statutes; means any natural person or entity
<br />organized under the laws of any state or of the United States with the legal power to enter into a binding contract and
<br />which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which
<br />otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers,
<br />directors, executives, partners, shareholders, emplo)'ees, members, and agents who arc active in management of any
<br />entity,
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<br />p.o ~~ 5A.'.J I (/VO - I--{ ll..l.QU
<br />(Printed or Typed Legal Name of Affiant)
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<br />State of r:l.c1L-1~Countyof M\.AJvt\-D~~
<br />Sworn to llnd subscribed before me this Z 4- day ofp.F'f2-\l.-
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<br />..-- .- --... -M: .JS... .AL. ............. __ ~~.
<br />, ..::.,~~~l~:,:;",.. EDEN JEAN CHAr..; t-S
<br />, 2007 b' l"m~ :~.~~ Notary Public. State of Flv1da
<br />[. . : . ~My Commission Expj'es Apr 21. 2008
<br />;~^' :'<l~i Commission # DD 42g83
<br />"";~ OF f~O\""
<br />""n,,'" Bonded By National tJotary Assn,
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<br />~d&1 rTeCU-t Ckay~
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<br />Notary's Name-Prirtf'ed, Stamped or Typed
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<br />Notary Seal:
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<br />Personally Known:
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<br />01' Produced Identification Lldentification Produced D I L.# ~ 460- 007 -C..:7~-t;7 ~ - 0
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<br />RFQ 07-03-01 Engineering Srvs Bridge Revised (Addendum I).doc
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