HomeMy WebLinkAboutexhibit1D3ATTACHMENT D3
Attachment D3
SWORN STATEMENT PURSUANT
ON PUBLIC ENT OITY CRiMES3) (a),
FLORIDA STATUT ,
THIS
FORM MUST BE SIGNED AND SWORN TO IN THE
PRESENCE OF A NOTARY PUBLIC OR
OTHER OFFICIAL AUTHORIZED TO ADMINISTER
1, This sworn statement is submitted to
by.
for
iami-Dade Count
(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: Florida Sta�u+
2. 1 understand that a "public entity crime" as definednparagraph
287.133
t .10 and1)(gectly related to the
means a violation of any state or federal law by a person transactions of business with any public entity or with an agencypolitical subdivision of any other
or
state or with the United States, Including, but not limited to, any bid or contract for goods or services
be provided to public entity or agency or political cs lbu v subdivision
f any other
conspiracy, stateorf the
matins
to
States and involving antitrust, fraud, theft, bribery,
misinterpretation.
fo L a
conviction of a public entity crime, with or without an
3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133 (1)(), bt by
Statutes, means a finding of guilt or
adjudication of guilt, in anyyEidersl or state trial court of record
verdict anon jury Ir altbor entry of a
indictment or information after July 1, 1989, as a result of a jury
plea of guilty or nolo contendere.
r}, 1 understand that an "affiliate" as defined in paragraph 287.133(1)(a orid
Fla Statutes, means:
1. A predecessor
or successor of a person convicted of a public entity crime; or 2. An entity under
the control
ol of any natural person who is active in the management of the entity and who has been
directors,
convicted of a public entity �eme.employees,
nTBoyeesmme blerse"andincludes
agentsthose
whoofficers,
active in the
executives, partners, shareholders, P one person of shares constituting a controlling
management in at of anr eriliate. Theownership of rqu by
or income among persons when not for fair
interest in another person, or a pooling rime facie case that one person
market value t under an arms length agreement, ntl shall me s into a a p joint preceding36 months shall beo
controls another person. A person who lcnowingyoridaeduring theventure with a person who
public entity crime in F
has been convicted of a
considered an affiliate.
5. 1 understand that a "person" as defined in Paragraph 287.133(1)(e)+ Florida Statutes, m eons any
organized under the laws of any state or
to theid United
States
contracts for within
provision
he legal
natura
power person n eentity g contact and which bids or applieslies to transact business
of goods or services
Into a binding arto r a shareholders,
a public entity, or which otherwise transacts °rap
of public
services let he term "person" includes those officers, executives, p
with a pes, entity•
employees, members, and agents who are active in management of an entity. true �n relation to the
p
statement. Please indicate which statement applies.)
Based on information and belief, the statement which I have marked below is
6' this sworn
entity submitting r any of its officers, directors, executives,
ees, members, o r a gents w ho are a ctive i n the management crime
Neither the entity submitting mploy this sworn statement, ni4h and convicted of a public
partners, nors harp affiliate of the entity has been charged w
entity, any 1489.
subsequent to July 1,
is w ho are a i ctive i n the °crime
submitting this sworn statement, or one or more of its officers, directors, executives,
t he
The entity to ees, members, o r a g management entity
eentity, nor, s any affiliate
of i Y with and convicted of a public
subsequent
any afi tit the Howentiever,
has been chargedand the Final before
a Head byg
1989. However, there has beenHearingssubsequent proceeding before a Hearing
Officer
the July of,Division of Administrative
the Hearing
ri State Florida, of the final order).
the Hearing ate Officer determined that it was not in the aplu9lcopyterest to place the entity sub
g
this sworn statement on the convicted vendor list. (aft
SUBMISSION OF THIS FORM TO THE CONTRA TING OR THAT PUBLICRFOR
I UNDERSTAND THAT THE S 1 (ONE)
ENTITYTNT PUBLIC ENTITY IDENTIFIED IN PARAGRAPH
THAT THIS FORM IS VALID THROUGH DECEMBEn�p TOF RN ORMCALENDAR
TOLD
ONLY AND, SO UNDERSTAND THAT 1 AM REQ
HAT
YEAR C ENTITY
IT IS RFILED. I
T IN
CESS OF
PUBLIC ENTITY PRIOR
TO ENTERING INTO A CONTRAUTES FOXR CATEGORY ET O OF ANY
AMOUNT PROVIDED INSECTION
CONTAINED N THIS FORM.
CHANGE IN THE INFORMATION
(Signature)
Sworn to and subscribed before me this day of
Personally known Notary Public "State of
OR Produced Identification My commission expires
('type of Identification)
(Printed typed or stamped commissioned name of notary
public)
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