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<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 />Neither 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 REQUIRED TO INFORM THE PUBLIC <br />ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT <br />PROVIDED IN SECTION 287.017, FLORIDA STATUTES For;CATEGORY TWO OF ANY CHANGE <br />IN THE INFORMATION CONTAINED IN THIS FORM, I <br /> <br />- + <br />I <br />,/WI / <br />-------[signature] <br /> <br />Sworn to and subscribed before me this <br /> <br />i7 <br /> <br />day of J-J\ 'j ,202'.], <br />--~~~. <br /> <br />/' .--- <br />Notary Public - State of r 10 \' \ d q <br /> <br />- <br /> <br />Personally known <br /> <br />v <br /> <br />OR Produced identification <br /> <br />(Type of identification) <br /> <br />My commission expires c.o} Co I ~O II <br /> <br />(Printed typed or stamped <br />com ' . of notary public) <br />$i\',j\~~ DeJon Valentine <br />~!~i1 Commission DO 682437 <br />~f.:l:R Th<t"{.~ Expires June 6, 2011 <br />, , .... Bonded Tlvu rillY Fain """"""'" 800-385-7019 <br /> <br />Final Version 6/07 <br /> <br />00402-2 <br /> <br />03-4197 <br />