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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 FO CATEGORY TWO OF ANY CHANGE
<br />IN THE INFORMATION CONTAINED IN THIS FORM.
<br />
<br />
<br />day of
<br />
<br />
<br />,20.0..&
<br />
<br />Sworn to and subscribed before me this \ '\
<br />
<br />Personally known
<br />OR Produced identification
<br />
<br />(Type of identification)
<br />
<br />My commission expires , 0 I~ JJ,o I \
<br />
<br />r(H\~ '-\ L. L..Lf\I\JE"~
<br />(Printed typed or stamped
<br />commissioned name of notary public)
<br />
<br />:'.,...,. I'" '" 1"1" 1111111" II 1'1" lit,,, WII' III.
<br />S MARIA 1... LLANeS ::
<br />S f.\\Illl/1Iflh Comm# 000721224 E
<br />. 1~ ~ .
<br />i \S~'<i ~.,j' Explrel10/212011 i
<br />. *';::{"Dffl,; :f .
<br />: ""'"1111' Florida Notary Assn., Ine :
<br />"..................1...1... .., II ..... II ..... Ii
<br />
<br />Final Version
<br />
<br />00402-2
<br />
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