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<br />THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR
<br />OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
<br />
<br />This sworn statement is submitted to CH~ of S VY'l f1 'I '1'< / f ~
<br />[print name of the public entity]
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<br />SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a),
<br />FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
<br />
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<br />by
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<br />[print individual's name and title]
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<br />[print name of e~tity submitting sworn statement]
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<br />for
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<br />whose business address is
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<br />and (if applicable) its Federal Employer Identification Number (FEIN) is
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<br />~zz 06P~/ 9
<br />
<br />2.
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<br />(If the entity has no FEIN, include the Social Security Number of the individual signing this
<br />sworn statement: JAr .)
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<br />
<br />I understand that a "public entity crime" as defined in Paragraph 287.133(1 )(g), Florida
<br />Statutes, means a violation of any state or federal law by a person with respect to and
<br />directly related to the transaction of business with any public entity or with an agency or
<br />political subdivision of any other state or of the United States, including, but not limited to,
<br />any bid or contract for goods or services to be provided to any public entity or an agency or
<br />political subdivision of any other state or of the United States and involving antitrust, fraud,
<br />theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.
<br />
<br />3.
<br />
<br />I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1 )(b),
<br />Florida Statues, means a finding of guilt or a conviction of a public entity crime, with or
<br />without an adjudication of guilt, in any federal or state trial court of record relating to
<br />charges brought by indictment or information after July 1, 1989, as a result of a jury
<br />verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.
<br />
<br />I understand that an "affiliate" as defined in Paragraph 287.133(1 )(a), Florida Statutes,
<br />means:
<br />
<br />4.
<br />
<br />5.
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<br />1. A predecessor or successor of a person convicted of a public entity crime; or
<br />2. An entity under the control of any natural person who is active in the management of
<br />the entity and who has been convicted of a public entity crime. The term "affiliate"
<br />includes those officers, directors, executives, partners, shareholders, employees, members,
<br />and agents who are active in the management of an affiliate. The ownership by one person
<br />of shares constituting a controlling interest in another person, or a pooling of equipment or
<br />income among persons when not for fair market value under an arm's length agreement,
<br />shall be a prima facie case that one person controls another person. A person who
<br />knowingly enters into a joint venture with a person who has been convicted of a public
<br />entity crime in Florida during the preceding 36 months shall be considered an affiliate.
<br />
<br />I understand that a "person" as defined in Paragraph 287.133(1 )(e), Florida Statutes,
<br />means any natural person or entity organized under the laws of any state or of the United
<br />States with the legal power to enter into a binding contract and which bids or applies to bid
<br />on contracts for the provision of goods or services let by a public entity, or which
<br />otherwise transacts or applies to transact business with a public entity. The term" person"
<br />includes those officers, directors, executives, partners, shareholders, employees, members,
<br />
<br />.,
<br />. Form PUR 7068 (Rev. 06/11/92)
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<br />....,
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<br />-
<br />
<br />09/09
<br />
<br />00402-1
<br />
<br />03-4122.F
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