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<br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br /> <br />6. Based on information and belief, the statement which I have marked below is true in relation to <br />the entity submitting this sworn statement. [Indicate which statement applies] <br /> <br />~either the entity submitting this sworn statement, nor any of its officers, directors, <br />executives, partners, shareholders, employees, members, or agents who are active in the <br />management of the entity, nor any affiliate of the entity has been charged with and convicted of a <br />public entity crime subsequent to July 1, 1989. <br /> <br />The entity submitting this sworn statement, or one or more of its officers, directors, <br />executives, partners, shareholders, employees, members, or agents who are active in the <br />management of the entity, nor any affiliate of the entity has been charged with and convicted of a <br />public entity crime subsequent to July 1, 1989. <br /> <br />The entity submitting this sworn statement, or one or more of its officers, directors, <br />executives, partners, shareholders, employees, members, or agents who are active in the <br />management of the entity, nor any affiliate of the entity has been charged with and convicted of a <br />public entity crime subsequent to July 1, 1989. However, there has been a subsequent <br />proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings <br />and the Final Order entered by the Hearing Officer of the State of Florida, Division of <br />Administrative Hearings and the Final Order entered by the Hearing Officer determined that it <br />was not in the public interest to place the entity submitting this sworn statement on the convicted <br />vendor list. [attach a copy of the final order] <br /> <br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR <br />THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY <br />ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN <br />WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM R IRED TO INFORM THE PUBLIC <br />ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXC S OF THE THRESHOLD AMOUNT <br />PROVIDED IN SECTION 287.017, FLORIDA STATUTES FO C \ EGORY TWO OF ANY CHANGE <br />IN THE INFORMATION CONTAINED IN THIS FORM. <br /> <br />Sworn to and subscribed before me this <br /> <br />11 day of <br /> <br /> <br />~ <br /> <br />Personally known <br />OR Produced identification <br /> <br />(fie v.L- <br /> <br />(Type of identification) <br /> <br />MY...f9DJmission'e:?<RlrJt~ <br />~ ::;;, PI,~ Notaf'{ PUO,II, ~ <br />o~\ ~'" Maflil V'Clonano 538B <br />.. I ~. .. A,," "",~"Ion C047 <br />(Fl~int~d typ-~d30rLlstaJDp <br />commissioneaname of notary public) <br /> <br />Final Version 6/07 <br /> <br />03-4197 <br /> <br />00402-2 <br />