HomeMy WebLinkAboutAttachment OAT T A CE' IENT -0
SWORN' STATEMENT PU SUAti'T TO SECTION 2S7.1=3(3)13i,
FLORIDA STATUTES. ON PUBLIC ENTITY CRIMES
THIS FORM MUST BE SIGNED AND SWORN TO F'NI THE PRESENCE OF A
NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER
OATHS.
1. This sworn statement is submitted to Miami -Dade County -
(print individual's name and title)
for
whose business address is
(print name of entity submitting sworn statement)
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:)
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
transaction of business with any public entity or with an agency or political subdivision of any
other state of the United States, including, but not limited to, any bid or contract for goods or
services to be provided to any public entity or an agency or political subdivision of any other state
of the United States and involving antitrust, fraud, theft, bribery, ,collusion, racketeering,
conspiracy, or material misrepresentation.
3. I 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 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, non jury trial, or entry of
plea of guilty or nolo contendere.
4. I understand that an "affiliate" as defined in Paragraph 287,133(1)(a) Florida Statutes, means:
A predecessor or successor of a person convicted of a public entity crime; or,
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 pooling of equipment or income
among persons when not fer 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 pubic entity crime in Florida
during. the precedins 36 months shall be considered an affiliate.
5. 1 understand that a "person" as defined in Parasraph 287.133(1)(e), Florida Statutes. means an natural
person or entity or Eanized under the iav,ts of any state or of the United States with the leea; power to
enter into a binding contract and which bids or applies to bid on contracs for the provision of roods or
services let by a public entiry, or which otherwise transacts or applies to transact business with a public
entity. The term "person" includes those officers, dire:tors, cr.ecutives, partners, shareholders,
employees, members, and agents who are active in management of an entity.
Based on information and belief, the statement, which 1 have marked below, is true in relation to The
entity submitting this sworn statement. (Please indicate ;vhich statement applies).
Neither the entity submitting this sworn statement, nor any of its officers, directors,
executives, partners, shareholders, employees, members, or agents \vho are active in the
management of the entity, nor the 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 an 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 an affiliate of the entity has been charged with an convicted of a
public entity crime within the past 36 ,months. However, there has.been a subsequent proceeding
before a Hearing Officer 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 swom 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 I (ONE) ABOVE IS FOR
THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH THE LIFE OF
THE CONTRACT. 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 287.0I7, FLORIDA STATUTES FOR CATEGORY TWO OF
ANY CHANGE IN THE INFORMATION CONTRAINED IN THIS FORM.
(Signature) (date)
STATE OF
COUNTY OF
PERSONALLY APPEARED BEFORE ME, the undersigned authority
(name of individual signing)
who, after, first being swot ,by me, affixed his/her signature in the space provided above on this
day of , 20
NOTARY PUBLIC
My commission expires: