HomeMy WebLinkAboutExhibit 3SWORN STATEMENT PURSUANT TO SECTION 287.133 (3) (a)
FLORIDA STATUTES ON PUBLIC ENTITY CRIMES
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A
NOTARY PUBLIC OR DTHER OFFICIAL AUTHORIZED TO ADMINISTER
OATHS
1. This form statement is submitted to
by
for
(Print individual's name and title)
(Print name of entity submitting sworn statement)
whose business address is
and if applicable its Federal Employer Identification Number (FEIN) is If the entity has
not FEIN, include the Social Security Number of the individual signing this sworn statement.
2. 1 understand that a "public entity crime" as defined in paragraph 287.133(1)(g), Florida Statues,
means 2.ViD12fon of any state or federal law by a person with respect to an directly related to
the transactions of business with any public entity or with an agency or political subdivision of
any other state or with the United States, including, but not limited to any bid or contract for
goods or services to be provided to public entity or agency or political subdivision of any other
state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering,
conspiracy, or material misinterpretation.
3. 1 understand that "convicted" or "conviction" as defined in Paragraph 287,133(1)(b), Florida
Statutes, means a finding of guilt or a conviction of a public entity crime, with or without an
adjudication of guilt, in an federal or state trial court of record relating to charges brought by
indictment or information after July 1, 1989, as a result of a jury verdict, non -jury trial, or entry of
a plea of guilty or nolo contendere.
4. 1 understand that an "Affiliate" as defined in paragraph 2B7.133(1)(a), Florida Statutes means:
1. A predecessor or successor of a person convicted of a public entity crime, or
2. An entity under the control of any natural person who 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, employees, members, and
agents who are active in the management of an affiliate. The ownership by one person
Of shares constituting a controlling interest in another person, or a ,cooling 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 knowingly enters into a joint venture with a person who has been convicted
of a public entity crime in Florida during the preceding 36 months shall be considered an
affiliate.
5. 1 understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statues, means any
natural person or entity organized under the laws of any state or of the United States within the
legal power to enter into a binding contract and which bids or applies to bid on contracts for the
provision of goods or entity. The term "person" includes those officers, executives, partners,
shareholders, employees, members, and agents who are active in management of an entity
6. Based on information and belief, the statement which I have marked below is true in relation to the
entity submitting this sworn statement. (Please indicate which statement applies.)
Neither the entity submitting sworn statement, nor any of its officers, director, executives,
partners, shareholders, employees, members, or agents who are active in the management of the
entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime
subsequent to July 1, 1989.
The entity submitting this sworn statement, or one or more of its officers, directors,
executives, partners, shareholders, employees, members, or agents who are active in the
management of the entity, .or an affiliate of the entity, or an affiliate of the entity had been charged
with and convicted of a public entity crime subsequent to July 1, 1989, AND (please indicate which
additional statement applies.
The entity submitting this sworn statement, or one or more of its officers, directors,
executives, partners, shareholders, employees, members, or agents who are active in the
management of the entity, nor any affiliate of the entity has been charged with and convicted of a
public entity crime subsequent proceeding before a Hearing Officer of the State 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 sworn statement
on the convicted vendor list. (attach a copy of the final order).
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER
FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC
ENTITY ONLY AND THAT THIS FORM IS VALID . THROUGH DECEMBER 31 OR THE
CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO
INFORM THAT PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE
THRESHOLD AMOUNT PROVIDED IN . SECTION 287.017 FLORIDA STATUTES FOR A
CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.
(Signature)
Sworn to and subscribed before me this day of 20
Personally known
Or produced identification
(Type of identification)
Notary Public -State of
My commission expires
(Printed, typed or stamped commissioned
name of notary public)