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<br />and agents who are active in management of an entity.
<br />
<br />6, Based on information and belief, the statement which I have marked below is true in
<br />relation to the entity submitting this sworn statement, [Indicate which statement applies]
<br />
<br />xx 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
<br />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,
<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
<br />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,
<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
<br />convicted of a public entity crime subsequent to July 1, 1989, However, there has been a
<br />subsequent proceeding before a Hearing Officer of the State of Florida, Division of
<br />Administrative Hearings and the Final Order entered by the Hearing Officer of the State of
<br />Florida, Division of Administrative Hearings and the Final Order entered by the Hearing
<br />Officer determined that it was not in the public interest to place the entity submitting this
<br />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
<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.
<br />
<br />~or7~
<br />
<br />[signature] U
<br />
<br />day of
<br />
<br />October
<br />
<br />,20~.
<br />
<br />Sworn to and subscribed before me this 20th
<br />
<br />Personally known xx
<br />OR Produced identification
<br />
<br />Notary Public - State of
<br />
<br />Florida
<br />
<br />(Type of identification)
<br />
<br />My commission expires Of I O:l./a..O I 0
<br />
<br />~~~i '_
<br />(Printe typed or stampea 0
<br />commissioned name of notary public)
<br />
<br />1:.-.... SUSAN RILEY I
<br />I ,.~~~l~~:Yrl'4;, ~v1v COMMISSION #00513781 i
<br />',~, F,XPIRES, JAN 02. 2010 ,
<br />'~-'~IU ,,~
<br />I '''0'0;; Bon1e(j thrrug!1 1 5t State Insurance
<br />
<br />Form PUR 7068 (Rev, 06/11/92)
<br />
<br />09/09
<br />
<br />00402-2
<br />
<br />03-4122.F
<br />
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