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O� SV ANY 'St��d <br />4 <br />r `'J yIOP�NO4 <br />Jf <br />Y OF SJT� <br />STATE OF FLORIDA ) <br />COUNTY OF 0 Q ) <br />ANTI - KICKBACK <br />City of Sunny Isles Beach <br />18070 Collins Avenue <br />Sunny Isles Beach, FL 33160 <br />Telephone: (305) 947 -0606 Fax: (305) 949 -3113 <br />ANTI - KICKBACK AFFIDAVIT <br />I, the undersigned, hereby duly sworn and deposed say that no portion of this sum herein Bid <br />will be paid to any employees of the City of Sunny Isles Beach or its elected officials as a <br />commission, kickback, reward or gift, directly or indirectly by me or any member of my firm or <br />by an officer of the corporation. <br />The foregoing instrument <br />, 20 , by <br />of person], as <br />executed]. <br />AFFIX NOTARY STAMP HERE: <br />By: �OZq-C.(A � 0f6 s_((u_S <br />Title: C V �& Cina. <br />was acknowledged before me this day of <br />(name <br />[type of authority], for <br />[name of party on behalf of whom instrument was <br />Notary Public — State of Florida <br />Print or Type Commissioned Name <br />Personally Known OR Produced Identification <br />Type of Identification Produced <br />DECEMBER28,2010 7 of 7 <br />