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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 swom 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 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.
<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 INF M THE PUBLIC ENTITY PRIOR TO ENTERING INTO A
<br />CONTRACT IN EXCESS OF THE THRESHO AMOU PROVIDED IN SECTION 287.017, FLORIDA
<br />STATUTES, FOR CATEGORY TWO OF ANY, C GE IN T FORMATION CONTAINED IN THIS FORM.
<br />By:
<br />
<br />
<br />(AFFIX NOTARY STAMP HERE)
<br />
<br />
<br />August
<br />
<br />, 20~, by
<br />
<br />Sworn to and subscribed before me this 1
<br />
<br />,!JlY Pile AM
<br />. MY c6"MI~~ ';~ "72~ignature: Notary Public - Stale of Florid.
<br />" *
<br />'" EXPIRES: May 3, 2011 11 --r-e-4'JJI. \.
<br />c-:,rE;OFfCo~<>" BondedThru Budget Notary Servlr'" ~ty) ~ 1:5 ~
<br />Print or Type Commissioned Name
<br />
<br />
<br />END OF SECTION
<br />
<br />60
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