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<br />.....
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<br />and agents who are active in management of an entity.
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<br />6.
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<br />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]
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<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
<br />convicted of a public entity crime subsequent to July 1, 1989.
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<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.
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<br />....
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<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]
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<br />,..,
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<br />,..,
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<br />,..,
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<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. ~
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<br />[si nature]
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<br />
<br />day of Och>bcv- , 20 ocr
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<br />~lW<<1_ '
<br />
<br />Notary Public - State of ~/tfi1d'i
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<br />,.,
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<br />Sworn to and subscribed before me this 2o-tl--\
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<br />,.,
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<br />OR Produced identification
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<br />5-~ ~ fV'VVVVv.i'V' V" ,
<br />(Type of identification) ~ <co~':P1,*,Q C'r J" TIiE/ L \ ,
<br />
<br />~'O, ~,:.-l~ \fYCf" , I'. III
<br />-so:F\.-V"{) EXI jh~ ",. lilt Id
<br />lJ. t- -l,~J \RY FI. '\., U\ ,.\,.
<br />"V\,f\ 'V~"'lJ"t.IV'\I'V'V'V'V\; d wF", "'.", "'"'-.,,~
<br />
<br />My commission expires /O/221M' 0
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<br />Cvnfh-ca. L.-Wa J fz.
<br />(Printed typed or stamped
<br />commissioned name of notary public)
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<br />
<br />Form PUR 7068 (Rev. 06/11/92)
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<br />1""1
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<br />09/09
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<br />00402-2
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<br />03-4122.F
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