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5r4 11 V !I,� <br />s <br />PUBLIC ENTITY CRIMES <br />City of Sunny Isles Beach <br />p' 18070 Collins Avenue <br />5.r n� . , ow`° Sunny Isles Beach, FL 33160 <br />Telephone: (305) 947 -0606 Fax: (305) 949 -3113 <br />SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a) <br />FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES <br />PUBLIC ENTITY CRIMES <br />Pursuant to the provisions of paragraph (2) (a) of Section 287.133, Florida State Statutes - "A person or affiliate <br />who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a <br />Bid on a Contract to provide any goods or services to a public entity, may not submit a Bid on a Contract with a <br />public entity for the construction or repair of a public building or public Work, may not submit Bids on leases of <br />real property to a public entity, may not be awarded to perform Work as a Contractor, supplier, Sub - Contractor, or <br />Consultant under a Contract with any public entity, and may not transact business with any public entity in excess <br />of the threshold amount Category Two of Sec. 287.017, FS for thirty six months from the date of being placed on <br />the convicted vendor list ". <br />THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER <br />OFFICIAL AUTHORIZED TO ADMINISTER OATHS. <br />11.1. This sworn statement is submitted to City of Sunny Isles Beach <br />by Sue- C(.W, l S Q <br />I pnrd incTivia—u s name ana tinel <br />for G L CU "bn,.0 -h-6 A 4n, C b� 1u �7� l�� s C�'t,A -eS <br />ilprint name Or entity submitting sworn statementJ <br />whose business address is: <br />tiE 1Lq s #33�v. /�► ;4�� I���b �L 3 3/ CO <br />and (if applicable) its Federal Employer Identification number (FEIN) is ,1oF't f Off:? <br />(If the entity had no FEIN, include the Social Security Number of the individual signing this sworn <br />statement: ) <br />11.2. 1 understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a <br />violation of any state or federal law by a person with respect to and directly related to the transaction of <br />business with any public entity or with an agency or political subdivision of any other state or with the <br />United States, including, but not limited to, any Bid or Contract for goods or services to be provided to any <br />public entity or an agency or political subdivision of any other state of the United States and involving <br />antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. <br />11.3. 1 understand that "convicted" or "conviction" as defined in Para. 287.133(1)(b), Florida Statutes, means a <br />finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any <br />federal or state trail court of record relating to charges brought by indictment or information after July 1, <br />1989, as a result of a jury verdict, non -jury trial, or entry of a plea of guilty or nolo contendere. <br />11.4. 1 understand that an "affiliate" as defined in Para. 287.133(1)(a), Florida Statutes, means: <br />a.) predecessor or successor of a person convicted of a public entity crime; or <br />b.) Any entity under the control of any natural person who is active in the management of the entity <br />and who has been convicted of a public entity crime. The term "affiliate" includes those officers, <br />directors, executors, partners, shareholders, employees, members, and agents who are active in <br />the management of an affiliate. The ownership by one person of shares constituting a controlling <br />interest in another person, or a pooling of equipment or income among persons when not for fair <br />DECEMBER 28. 2010 2 of 7 <br />