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market value under an arm's lengtb aEreement, shall be a prime facie case that one person
<br />controls another person. A person who knowingly enters into a ioint venture with a person who
<br />has been convicted of a public entity crime in Florida during the preceding 36 months shall be
<br />considered an affiliate.
<br />{1.5. I understand thal a "person" as defined in Para. 287 .133(1)(e), Florida Statules, means any natural
<br />person or entity organized under the laws of any state or of the United States with the legal power to
<br />enter into a binding Contract and which Bids or applies to Bid on Contracls for the provision of goods or
<br />services let by a public entity, or which otherwise transacts or appljes to transact business with a public
<br />entity. The term "persons" includes those officers, directors, executives, partners, shareholders,
<br />employees, members, and agents who are active in management of any entity.
<br />I 1.6. Based on information and belief, the statement which I have marked below is true in relation to the entity
<br />submitting this sworn statement. (lndicate which statement applies.)
<br />X Neither the entity submitting this sworn statement, nor any of it's officers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in the management of the entity, nor any
<br />affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1,
<br />1989.
<br />The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in the management of the entity, or an
<br />affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1,
<br />1989.
<br />The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
<br />shareholders, employees, members, or agenls who are active in the management of the entity, or an
<br />affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1,
<br />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 interesl to place the entity submitting this sworn statement on the
<br />convicled vendor lisl. (Attach a copy of the final order.)
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORI\il TO THE CONTRACTING OFFICER FOR THE
<br />PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBLIC ENTIry ONLY AND,
<br />THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I
<br />ALSO UNDERSTAND THAT I AM REQUIRED TO INFORI\4 THE PUBLIC ENTITY PRIOR TO ENTERING INTO
<br />A CONTRACT IN EXCESS OF THE THRESHOLD AI\,4OUNT PROVIDED IN SECTION 287.017, FLORIDA
<br />STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFORI\4ATION CONTAINED IN THIS FORM-
<br />(Prinled Name)
<br />President
<br />(Title)
<br />Sworn to and subscribed before me this /3 day of_D9.g9!Ibq_, 20 16 , by
<br />By:
<br />Signature:
<br />OR Produced ldentification
<br />Type of ldentification Produced
<br />10/1998
<br />SIEPHANIE POLO
<br />MY CoMMlSstoN # GG 002356
<br />EXP|REST Jlty 23, 2020gonaeO ruu tfofery p;r4lic Unaerwriroc
<br />3ofl0
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