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<br />officers, directors, executives, partners, shareholders, employees, members, and agents who are active in
<br />management of any entity.
<br />
<br />11.6. Based on information and belief, the statement which I have marked below is true in relation to the entity
<br />submitting this sworn statement. (Indicate which statement applies.)
<br />
<br />_ 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 affiliate of the
<br />entity has been charged with and convicted of a public entity crime subsequent to July 1,1989.
<br />
<br />_ The entity submitting this swom 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 affiliate of the
<br />entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989.
<br />
<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 affiliate of the
<br />entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has
<br />been a subsequent 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 Administrative Hearings and the
<br />Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity
<br />submitting this sworn statement on the convicted vendor list. (Attach a copy of the final order.)
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC
<br />ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS
<br />FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO
<br />UNDERSTAND THAT 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, FLORIDA
<br />STATUTES, FOR CATEGORY TW~ ~F ANY, ~ I~ TH~ORMATION CONTAINED IN THIS FORM.
<br />
<br />y. .. 6't~ / ~--~
<br />/1Si atur....-- (/
<br />/h,? . ?~/<LCJ
<br />0Pr'~d Na e) ~
<br />
<br />(Title)
<br />)J1 II
<br />Sworn to and su~ribed before me this 1L- day of HAj IA~.3 f
<br />r )-" \ 'T I. m?A :,.- D .
<br />I
<br />
<br />(AFFIX NOTARY STAMP HERE) )1/J/i jJk7 H/i at.J! I) (-/ /;/,: i
<br />.J '--
<br />
<br />
<br />~
<br />~
<br />
<br />./) r
<br />,2lT_, by
<br />
<br />_.~':J/J'I::tt.. KAREN KRAFT BADER
<br />t::riJJ~~ MY COMMISSION' DO 396488
<br />~ . ! EXPIRES: May 22, m
<br />, ,P.f.;r.l' BcndIld 1llru Nda1y PIdc Undlrwltllrl
<br />
<br />Signature: Notary Public - State of Florida
<br />
<br />Kar'{("\ t(,\A 8.q&'G~-)
<br />Print or Type Commissioned Name
<br />
<br />Personally Known ~ OR Produced Identification
<br />Type of Identification Produced
<br />
<br />'...;
<br />
<br />END OF SECTION
<br />
<br />60
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