HomeMy WebLinkAboutexhibit1D3ATTACHMENT D3
Attachment D3
SWORN STATEMENT PURSUANT TO SECTION 287.133 (3) (a),
FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
THIS FORM CMUST BE SIGNED AND IAUTHORIZED TO ADMINISTER ER OATHS PRESENCE TO IN THE OF A NOTARY PUBLIC OR
OTHER OF
1. This sworn statement is submitted to Miami -Dade County
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 no FEIN, include the Social Security Number of the individual signing
this sworn statement:
2. I understand that a "public entity crime" as defined in paragraph 287.133 (1)(g),
Florida Statutes,
means a violation of any state or federal law by a person with respect to and directly related to the
transactions of business with any public entity or with an agency or political
subdivisionact for of
or any o her
state or with the United States, including, but not limited to, any or
contbe pandiinvolvio ng antitrustic , fraudor , theft,ncy rbribery,political
col collusion, racketeering, conspiracy,r state or f the or material
States and g
misinterpretation.
3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133 (1)(b), Florid%
Statutes, means a finding of guilt or a conviction of a public entity crime, with or without an
or state trial court of record relating to
brought by
adjudication
ent or information after Julylt, in any 11, 1989, as a result of a jury verdict, non jury trial, s
indictment
entry of a
plea of guilty or nolo contendere.
4, I understand that an "affiliate" as defined in paragraph 287.133(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,
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 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
rs into a
erson who
has convicted her e of a• ublicrson entityho knowingly cr me in Florida during the joint
pr ceding 36 months hall be
has been P
considered an affiliate.
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5. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Sta utes, m eans 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 contact and which bids or applies to bid on contracts for the provision
of goods or services let by a public entity, or which otherwise transacts or applies to transact business
with a public entity. The term "person" includes those officers, executives, partners, shareholders,
employees, members, and agents who are active in management of an entity.
ow is
6. Based on information wo belief, ementt (Please indicate which statement atement which I have marked lapplies.) e in relation to the
entity submitting this s
Neither the entity submitting this sworn statement, nor any of its officers, directors, executives,
partners, s hareholders, e mployees, members, o r a gents w ho are a ctive i n the management o f t he
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, are a ctive n the
ns hareholders, e m he entity hasbeencharggedswit hand convicted of a public entity crime
entity, nor any affiliate of h'
subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing
Officer of the State of Floridthat it was not inthepubive lic in#egs and the rest to place inal theentty submier tting
by
the Hearing Officer determined
this sworn statement on the convicted vendor list. (attach a copy of the final order).
Y UNDERSTAND THAT THE SUBMISSION p OFTHIS H M TO THE
ASOVECONTRACTING
SCFOR THAT PUBLIC
ICER FOR
THE PUBLIC ENTITY IDENTIFIED INECEMBER 31 OF THE
ENTITY ONLY AND, THAT THIS FORM THAT THROUGHlAM REQUIRED TO INFORM CALENDAR
YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THRESHOLD
PUBLIC ENTITY PRIOR TO ENTERINGB1INTO LA CpNTATUSES FOR CATEGOI2YIN EXCESS OF ETW0 OF ANY
AMOUNT PROVIDED IN SECTION
CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.
(Signature)
da of , 20
•
Sworn to and subscribed before me this y
Personally known
OR Produced Identification
Notary Public - State of
My commission expires
(Type of identification)
(Printed typed or stamped commissioned name of notary
public)
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