HomeMy WebLinkAboutCertificationCERTIFICATION REGARDING LOBBYING
Certification for Contracts, Gi ants, Loans, and Cooperative Agreements
The undersigned certifies to the best of his or her knowledge and belief, that:
(7) 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, Ioans, 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.
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Name of Applicant
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Print name of Certifying Official
1
Signature of tifying Official
e-
Date
4'
City of
STATE OF FLORIDA
The foregoing instrument was acknowledged before me this day of \. , 200 C.
b=\r, who is personally known to me or who
(name of person whose signature is being notarized)
produced
(Type of Identification)
as identification, and who did/did not take an oath.
My commission expires '\O`k1 \
(Print Name)
SEAL
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c •My Commission DD3632t
'4 f < Expires. October 17 200E
6,0, Ibiset Salinas
:4; My Commission Dp3632E2
1ocn:i Expires October 17 2008
4S
CERTIFICATION REGARDING DEBARMENT, SUSPENSION & OTHER
RESPONSIBILITY MATTERS
PRIMARY COVERED TRANSACTIONS
1. The applicant certifies to the best of its knowledge and belief, that it and its principals:
Are not presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded frona 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
judgment 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.
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Applilicant/Ageiy
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Print Name or Certifying Official
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Signature of Cer i fying Official
i) )
Date
49
City of �..
STATE OF FLORIDA
The foregoing instrument was acknowledged before me this 3 day of , 200 tv
by (rtc��N
who is personally known to me or who
(name of person whose signature is being notarized)
produced 'l_ ' 1•- ' as identification, and who did/did not take an oath.
(Type of Identification)
(Print Name)
My commission expires 41\04) •
SEAL
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•y My Commission D0363282
�OF FL Expires October 17 2008
50
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 ADMINI ER OATHS. �p
1. This swom statement is submitted to I it, tUk VL� +ir4VLI
By
y-r) 11A— CCUd Foon.bt�
(Print this individual's name a title)
for L,TcL C tici v, �LL C,
(Prit nathe of entity S'Ibmittingstatements)
whose business address is
e w cc r CIA ; FloociT
and whose Federal Employer Identification Number (FE1N) is f Fte-r.10
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 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.
4. I understand that an "affiliate" as defined in paragraph 287.133(1)(a), Florida Statutes, means:
o. 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 hid on contracts for the
51
STATE OF FLORIDA
;7 day of
. 200 C.- by
who is Personally known to me
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.
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 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 T r1170RMATION CONTAINED IN THIS FORM.
Signature
City of
Sworn and subscribed before me this
Or who produced identification -
NOT
(-g%nature) (Print Name)
(Type of Identification)
My commission expires. \ \\ \ 1 3-c)c
SEAL
a, i Ibiset Salinas
f�> My Commission DD363282
""or Expires October i 752038