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HomeMy WebLinkAboutAttachment OSWORN ST.ATE}JE:,�T PURSUANT TO SECT] ON 133 (3) is , FLOP JDA STATUTES, O,N PUBLIC ENTITY CRI. -M PS THIS FORM MUST DE SIGNED AND TO lid THE PRESENCE OF .- PUBLIC OR C)TH.ER OFFICIAL ALiTH0RJZED TO ADI\41"NISTER OATHS. I. This sworn statement is submitted to A7iami-Dade County: (print individual's name and title) for (print name of entity submitting sworn staler-irm) whose business address is and (if applicable) i-ts Federal Employer Identification Number {FEIN) is—6O0©3%� (if the entity has no FEIN, include the Social Security Number of the individual signin; this sworn statement:) ?. I understand that a "public entity crime as defined in Paragraph 2E7.133(1)(g), Florida Statutes means a violation of any state or federal late by a person with respect to and directly related to the transaction of business .vith any public entity or with an agent' or political subdivision of any Other state of the United States, including, but rot limited to, any bid or contract for goods or services to be provided to any public entity 0, an agency or Political subdivision of any other stare Of the United States and involving anritrust, fraud, theme, bribery, Collusion, rackereering, conspiracy, or marerial misr epresertarion. I understand that "convicted" or "conviction" as defined in Paragraph 357.133(1)(b) Florida Statutes, means a finding of guilt or a cenvietion of a public entity entre, with or without an adjudication of ,;wilt, in any federal or state trial cowl of record relating to charges brought by . indictment or information after July 1, 1959, as a result ofa jury verdict, non jury trial, or entry of p11ea of guilty or nolo contendere. 4_ 1 understand that an "affiliate" as defined in Paragraph 357.133(1)(a) Florida. Statutes, means: a. A predecessor or successor of a person convicted of a public entity crime, or, b. An entity under the control of any natural persnn wino is active in the management of the entity and who has been convicted of a public entity crime. The term "affiliate: includes those Officers, directors, executives, partners shareholders, errtp)nyees, members, and agents tvho are active in the mananetneni of. an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that one person controls another person. A person Who }'no',vin,ly enters into a joint venture With a person who has been convicted ofa pubic entity crime in Florida during the preceding 3o months shall be considerer; an affiliate. >. I understand that a "person" as defined in Paragraph 357.1:3(1)(e), Florida Statutes means any natural person or entity' OrPanl'ed ander the 1av"s Of any s[ai'. Or of [.;e Lin iied States wit l the les,2) power to enter into a bind,nR conrrCCt and which bids or applies to bid oCpnti2C:5 for 111: pi01`iSiCn of LoodS or services )et b,,' a public entity; ar WhiCh othen�'ise r. transacts or applies to transact business v,i,h a public entrap,. The terin "parson" Inc)udos :hose 0Mc-rs, dlr'_itors, e`:eCJ[! ?;, p nners, shareholders, nlp•]0 "''_s, IT e177DerS, and a:L enis ',vho are active In mana^emmr of an emin', 6. BESed on !niCrmat!on and b�11= , t,^` r` IeTeni, \t'rlch 1 h2l'" nl2ri: help'•',', 15 rrlle !n rei2-!On i0 ih` tntrt}'subminino INS s�'.'orn staitmeni. (Please indicant „hich Slate eat 2pnJifft Neither the eniih' submirinS IhIS $v'Ortt Stale,7rCnt, nor an} of it OTTICerS, dlreclors, e:;e utrves, partners, shareho)ders, employees, members, or agents \',ho are acli;'e in the management of the emit)', nor the affiliate of the en:iry has been char_,ed wish and convicted of a public entity crime v,-iti In the past 36 months. The entity submirting this s\',orn statement, or one or more of its oflicers, directors, executives, panners, shareholders, employees, members, or aflents \5'1lo are active in the management of the entity, or an affiliate of the entity has been charged vrirh an convicted of a public entity crime within the past 36 months AND (P)ease indicate which additional statement applies) The entity submitting this sworn statement, or one or more of its officers, directors, executives, panners, shareholders, employees, members, or agents who are active in the management of The entity, or an affiliate of the entity has been charted with an convicted of a public entity crime within the past 36 months. Noweve.r, there has been L subsequent proceeding before a Hearing Ofricer of the State of Florida, division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this swom statement on the convicted vendor list (attach a copy of the final order). I UNDERSTAND THAT THE SUBMISSION OF THIS FORK TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED. IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORA? IS VALID THROUGH THE LIFE OF THE CONTRACT, I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR. TO ENTERING INTO A CONTRACT IN EXCESS OF THE 'THRESHOLD AMOUNT PROVIDED IN SECTION 287.0I7, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANfE IN THE INFORMATION CONTRAINED IN THIS FORM. STATE OF LO 24 COUNTY OF T)P.�) 'Z- PERSONALLY APPEARED BEFORE ME, the undersigned auth who, after, first being s-wom by me, affixed his/her signature in the t day oft, 20bf� 4 JACQUELYN D. Ml' CDAfMtSStON # UD EXPIRES: March 4, ' t t 9l k Bonded Tt�v NoJary P tic tars (nam of ind!vid 1 signing) e ro\'ided above on this NOTARY PUBLIC My commission e>:pires: