HomeMy WebLinkAboutSworn StatementSWORN STATEMENT PURSUANT TO SECTION 287.133(3)(A).
FLORIDA STATUTES ON PUBLIC ENTITY CRIME
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC
OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
I. This sworn statement is submitted to City of Miami, Department of Community Development
By Ardo Mesa, Chairman
(Print this individual's name and title)
for Allapattah Community Action., Inc.
(Print name of entity submitting statements)
whose business address is2257 N.W. North River Dr. Miami, Fla. 33125
and whose Federal Employer Identification Number (FEIN is 59-20000654
If the entity has no FEIN, include the Social Security Number of the individual signing this sworn
Statement: N/A
2. I understand that a "public entity crime" as defined in paragraph 287.133(1)(a), Florida Statutes
mean 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 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 any public entity or any agency or political subdivision of any other state
or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering,
conspiracy, or material misrepresentation.
3. I understand that "convicted" or "convection" 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
adjudication of guilt, in any 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, nonjury trial, or entry of a
plea of guilty or nolo contendere.
I understand that an "affiliate" as defined in paragraph 287.133(1)(a), Florida Statutes, means:
a. A predecessor or successor of a person convicted of public entity crime; or --
b. 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 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 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. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any
natural person or entity organized under the laws of any state or of the United States with the legal
power to enter into a binding contract and which bids or applies to bid on contracts for the
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provision of goods or services let by a public entity, or which otherwise transacts or applies I.)
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.
6. Based on information and belief, the statement which I have marked below is true in a relation to
the entity submitting this sworn statement. (Please indicate which statement applies).
x Neither the entity submitting this sworn statement, nor any of its officers, directors,
executives, partners, shareholders, employees, members, or agents who are active in the
management of the entity, or any affiliate of the entity has been charged with and convicted of a
public entity crime within the past 36 months.
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 has been charged with and convicted of a
public entity crime within the past 36 months. 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, or agents who are active in the management of the entity, or an affiliate
of the entity has been charged with and convicted of a public entity crime within the past 36
months. However, there has been a subsequent proceeding before a Hearing Officers of the State of
Florida, Division of Administrative Hearings and the Final Order 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. (Attached is 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 THE PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH
DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED AND FOR THE
PERIOD OF THE CONTRACT ENTERED INTO, WHICHEVER PERIOD IS LONGER. 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 287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY
CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.
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City of 4/(---// STATE OF FLORIDA
Swom and subscribed before me this day of A--r--1
0
,2005 by
who is Personalty known to Me
Or who produced identification -
(Type of Identification)
NOTARY PUB
(Signature)
4 6 S 4--c) My commission expires
(Print Name)
SEAL
Dolores Valdes olero
• My Commission DD024208
or 1Expires September 14, 2005