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<br />6. Based on information and belief: the statement which I have marked below is true in a relation to
<br />the entity submitting this sworn statement. (Please indicate which one (1) of the following three
<br />(3) statements is applicable.)
<br />
<br />_ (1) Neither the entity submitting this sworn statement, nor any of its officcrs, directors,
<br />exeeutivcs, partners, shareholders, employees, members, or agents who are active in the management
<br />of the entity, or any affiliate of the entity has been charged with and convicted of a public entity
<br />crime within the past 36 months.
<br />
<br />(2) The entity submitting this sworn statement, or one or more of its otlieers, directors,
<br />exceutives, partners, shareholders, employees, members, or agents who are active in the management
<br />of the entity, or any affiliate of the entity has bccn charged with and convicted of a public entity
<br />crime within the past 36 months.
<br />
<br />_(3) The entity submitting this sworn statement, or one or morc of its officers, dircctors,
<br />exccutivcs, partncrs, shareholders, employees, members, or agents who are active in the managemcnt
<br />of the entity, or agcnts who are active in management of the entity, or any affiliate of the entity has
<br />been charged with and convicted of a public entity crime within the past 36 months. However, there
<br />has been a subsequent proceeding before a Hearing Officers of the State of Florid~, Division of
<br />Administrative Hearings and the Final Ordcr by the Hearing Officer determined that it was not in the
<br />public interest to place the entity submitting this sworn statement on the convicted vendor list.
<br />(Attached is a copy of the final order.)
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING
<br />OFFICER FOR THE PUBLIC ENTITY IDENTIFIED TN PARAGRAPH I (ONE) ABOVE IS FOR
<br />THE PUBLIC ENTITY ONL Y AND, THAT TI.IIS FORM IS VALID THROUGH DECEMBER 31
<br />OF THE CALENDAR YEAR IN WHICH IT IS FILED AND FOR THE PERIOD OF THE
<br />CONTRACT ENTERED INTO, WHICHEVER PERIOD IS LONGER. I ALSO UNDERSTAND
<br />THA T I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A
<br />CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017,
<br />FLOUDA STATUTES FOR THE CATEGORY TWO OF ANY CHANGE IN THE
<br />INF RMA nON CONTAINED TN THIS FORM.
<br />
<br />
<br />I" Ar'V\f.,; ~ A 'PE' ALa elL
<br />(Printed or Typed Legal Name of Affiant)
<br />
<br />State of fl-o'j2.\OA County of 1?\<-Dvl I\.:p..i)
<br />Sworn to and subscribcd bcforc mc this aOIH day of
<br />
<br />A,\J("\JS,
<br />
<br />, 2007 by
<br />
<br />fA M A1Z-A
<br />
<br />f'€' t'\ C (Ie fC-
<br />
<br />.../'
<br />
<br />Notary Sl?al:
<br />". .. .'.-. .
<br />t".:,.'l" .
<br />(>J~/ \ ',~ :'.
<br />
<br />1f1y Cti.~lr:jj.,,,',,~:'iL L'l
<br />
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<br />
<br />'Ro13(E'F?-'r A. M vp..a(,~t>,J
<br />Notary's Name Printed, Stamped or Typed
<br />
<br />or Produced Identification
<br />
<br />Personally Known:
<br />
<br />Identification Produced
<br />
<br />14
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