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.
1. This sworn statement is submitted to (ems dam` �f/a /
By
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(print this individual's name and title)
(print name of entity submitting statements)
whose business address is ���
and if applicable is Federal Employer Identification Number' (FEIN) is w,5�--z;. ?--✓36i/,7
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(1Xa), Florida Statutes, means:
i. 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 Horida 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 provision of goods or services let
by a public entity, or which otherwise transacts or applies to transact business with a public entity. The tern
"person" includes those officers, executives, partners, shareholders, employees, members, and agents who are
active in management of an entity.
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).
yNeither 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 1S VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR
IN WHICH 1T 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
PROVID ' SECTION 287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY CHANGE
I.N TFIE INF RMATIC O, . NED THIS FORM.
Sworn to me and subscribed before me this 15 day of
Personally known J It / 7; iZ et
Or produced identification
(Type of Identification)
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