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<br /> ® ,r PUBLIC ENTITY CRIMES
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<br /> ® City of Sunny Isles Beach
<br /> `my' 18070 Coffins Avenue
<br /> •® *, :'o,sat`a Sunny Isles Beach,Fl 33160
<br /> Telehon
<br /> sun���•, 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 /> �i 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 /> 0 OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
<br /> ® 11.1. This sworn statement is submitted to City of Sunny Isles Beach
<br /> ® by >� - her Urreo, J�� nctgi�►
<br /> Ipnn m flier
<br /> s name and ptlej
<br /> ® for �'IGtG / / 144 e G
<br /> pp Loma name o entity submitting svmm statement] L c
<br /> X11 whose business address is: j 1 0 4440 v ( (�1
<br /> ® SC4V11/4 y ILs -wrack Ft 33160 _
<br /> ® and Of applicable) its Federal Employer Identification number(FEIN) is 4S s 2— 6P/ 73
<br /> ® (If the entity had no FEIN, include the Social Security Number of the individual signing this sworn
<br /> ® statement: .)
<br /> ® 11.2. I 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. I 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 nob contendere.
<br /> ® 11.4. I 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 /> 0 b.) Any entity under the control of any natural person who is active in the management of the entity
<br /> gf 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
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