HomeMy WebLinkAboutCertification Regarding lobbyingCERTIFICATION REGARDING LOBBYING
Certification for Contracts, Grants, Loans, and Cooperative Agreements
The undersigned certifies to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid, or will be paid, by or on behalf of the undersigned, to any
person for influencing or attempting to influence an officer or employee of an agency a Member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any
Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any
cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid to any person for influencing or attempting
to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or
an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative
agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report
Lobbying," in accordance with its instructions.
(3) This undersigned shall require that the language of this certification be included in the award documents for
"All" sub -awards at all tiers (including subcontracts, sub -grants, and contracts under grants, loans, and cooperative
agreements) and that all sub -recipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was made
or entered into. Submission of this certification is a pre -requisite for making or entering into this transaction
imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be = '
subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
APPLICANT
PRINT NAME OF CERTIFYING
SIC ATURE QF CERT •FFICIAL DATE
* Note: In these instances, "All" in the Final Rule is expected to be clarified to show that it applies to
covered contract/grant transactions over $100,000 (per QMB).
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CERTIFICATION REGARDING DEBARMENT, SUSPENSION AND OTHER
RESPONSIBILITY MATTERS PRIMARY COVERED TRANSACTIONS
I. The applicant certifies to the best of its knowledge and belief, that it and its principals:
a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal department or agency.
b. Have not within a three-year period preceding this proposal been convicted of or had a civil
judgement rendered against them for commission of fraud or a criminal offense in connection with
obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract
under a public transaction; violation of Federal or State antitrust statutes or falsification or destruction
of records, making false statements, or receiving stolen property;
c. Are not presently indicted for or otherwise criminally or civilly charged by a government entity
(Federal, State, or local) with commission of any of the offenses enumerated in paragraph 1.b of this
certification; and
d. Have not within a three-year period preceding this application/proposal had one or more public
transactions (Federal, State, or local) terminated for cause or default.
2. Where the prospective primary participant is unable to certify to any of the statements in this certification, such
prospective participant shall submit an explanation to the City of Miami.
UIr1 Chu \(
AP IC T/AGENCY
Gi. a Ot-,
PRINT NAM G OFFICIAL
SI
OF C1,RTIFY
OF C FYING OFFICIAL DATE
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SWORN 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
This sw rM statement is submitted to t � 01C.1.Q GIQ �.�i d th1'�-.RA
By11 -.N
(print this individual's name and title)
for
(print name of entity submitting statements)
t whose business address is 40 U L5:)
a3iz
and if applicable is Federal Employer Identification Number (FEIN) is r
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)(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 dny 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(l)(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.
4. I understand that an "affiliate" as defined in paragraph 287.5.33(1)(a), Florida Statutes, means:
1. A predecessor or successor of a person convicted of 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 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.I33(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 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 aie
active in management of an entity.
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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).
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 subnutting 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 I (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.
Sworn to me and subscribed before me this day of t i ni , 2004
Personally known
Or produced identification
(Type of Identification)
?s�rcp Sheila Salomon
GI �nmir�:�i�sr� 1E53!
Notary Public —State of 4 0-c.
My commission n :expires a 41 0 9' / d00
(Printed, typed or stamped commissioned name of notary public)
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