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1 <br /> 6. Based on information and belief, the statement which I have marked below is true in relation to <br /> the entity submitting this sworn statement. [Indicate which statement applies) <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 convicted of a <br /> public entity crime subsequent to July 1, 1989. <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 convicted of a <br /> public entity crime subsequent to July 1, 1989. <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 convicted of a <br /> public entity crime subsequent to July 1, 1989. However, there has been a subsequent <br /> proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings <br /> and the Final Order entered by the Hearing Officer of the State of Florida, Division of <br /> Administrative Hearings and the Final Order entered by the Hearing Officer determined that it <br /> was not in the public interest to place the entity submitting this sworn statement on the convicted <br /> vendor list. [attach a copy of the final order] <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. <br /> 1 [signature] <br /> Sworn to and subscribed before me this day of , 20_. <br /> Personally known <br /> OR Produced identification Notary Public - State of <br /> My commission expires <br /> (Type of identification) <br /> (Printed typed or stamped <br /> commissioned name of notary public) <br /> 1 <br /> 1 <br /> 1 <br /> 05/08 Final Version 00402-2 05-4893 <br />