Attachment_G_Notarized_Florida_Statutes_on_Public_Entity_Crimes_Certification.pdf

ATTACHMENT G

Notarized Affidavit

FLORIDA STATUTES ON PUBLIC ENTITY CRIMES CERTIFICATION

The State of Florida has enacted a law that requires Respondent(s), to submit a sworn document stating whether or not a corporation, its officers, predecessors or successors have been convicted of a public entity crime. Neither the Respondent, nor any officer, director, executive, partner, shareholder, employee, member or agent who is active in the management of the Respondent nor any affiliate of the Respondent shall have been convicted of a public entity crime subsequent to July 1988.

All type Respondents must read and complete in its entirety, sign and have notarized the attached “Sworn Statement under Section 287.133 (3) (a), Florida Statutes, on Public Entity Crimes.”

Failure to do so will result in the submission being considered non-responsive and therefore not considered for award.

Solicitation No.>#

SWORN STATEMENT UNDER SECTION 287.133 (3) (A),

STATE OF________________________________

COUNTY OF______________________________

Before me, the undersigned authority, personally appeared _________________________who, being by me first duly sworn, made the following statement:

1.The business address of________________________ (name of Respondent or contractor) is__________________________________

2. My relationship to ____________________________ (name of Respondent or contractor) is___________________________________ (relationship such as sole proprietor, partner, president, vice president).

3. I understand that a public entity as defined in Section 287.133 of the Florida Statues includes 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 in Florida or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any Solicitation or contract for goods or services to be provided to any public entity or such an agency or political subdivision and involving antitrust, fraud, theft, bribery, collusion, racketeering conspiracy, or material misrepresentation.

4. I understand that “convicted” or “conviction” is defined by the statue to mean a finding 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

5. July, 1989, as a result of a jury verdict, non-jury trial, or entry plea of guilty or nolo contender.

6. I understand that “affiliate” is defined by the statue to mean (1) a predecessor or successor of a person or a corporation convicted of a 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, or (3) those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate, or (4) a person or corporation who knowingly entered into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months.

7. Neither the Respondent or contractor nor any officer, director, executive, partner, shareholder, employee member or agent who is active in the management of the Respondent or contractor nor any affiliate of the Respondent or contractor has been convicted of a public entity crime.

(Draw a line through paragraph 7 if paragraph 8 applies)

8. There has been a conviction of a public entity crime by the Respondent or contractor, or an officer, director, executive, partner, shareholder, employee, member or agent of the Respondent or contractor, or an officer, director, executive, partner, shareholder, employee, member or agent of the Respondent or contractor who is active in the management of the Respondent or contractor or an affiliate of the Respondent or contractor. A determination has been made pursuant to Section 287.133 (3) by order of the Division or Administrative Hearings that it is not in the public interest for the same of the convicted person or affiliate to appear on the convicted Respondent list. The name of the convicted person or affiliate is____________________________. A copy of the order of the Division of Administrative Hearing is attached to this statement.

Affiant’s Signature

State of Florida County of ___________________

Sworn to and subscribed before me, a Notary Public, for the above State and County on this

_____________ Day of _____________________, 20____.

(Affix Official Seal) Notary Public Signature

Commission Expiration