Required_Forms_and_Affidavits_(no_bonds).pdf

AMERICANS WITH DISABILITIES ACT

(ADA) DISABILITY NONDISCRIMINATION

STATEMENT

THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR

OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS

This sworn statement is submitted to the CITY OF COOPER CITY, FLORIDA by:

(print individual’s name and title) for:

(print name of entity submitting sworn statement) whose business address is:

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, being duly first sworn state:

That the above named firm, corporation or organization is in compliance with and agreed to continue to comply with, and assure that any subcontractor, or third party contractor under this project complies with all applicable requirements of the laws listed below including, but not limited to, those provisions pertaining to employment, provision of programs and services, transportation, communications, access to facilities, renovations, and new construction.

The American with Disabilities Act of 1990 (ADA), Pub. L. 101-336, 104 Stat 327, 42 USC 1210112213 and 47 USC Sections 225 and 661 including Title I, Employment; Title II, Public Services; Title III, Public Accommodations and Services Operated by Private entities; Title IV, Telecommunications; and Title V, Miscellaneous Provisions.

The Florida Americans with Disabilities Accessibility Implementation Act of 1993, Section 553.501-553.513, Florida Statutes:

The Rehabilitation Act of 1973, 229 USC Section 794;

The Federal Transit Act, as amended 49 USC Section 1612; The Fair Housing Act as amended 42 USC Section 3601-3631.

Signature

BUSINESS ENTITY AFFIDAVIT

I, , being first duly sworn state:

The full legal name and business address of the person(s) or entity proposing to contract or transact business with the City of Cooper City ("City") are (Post Office addresses are not acceptable), as follows:

Federal Employer Identification Number (FEIN) (If none, Social Security Number) Name of

Entity, Individual, Partners or Corporation

Doing Business As (If same as above, leave blank)

Street Address City State

State and Date of Incorporation:

Signature of Affiant Date

Print Name Date

SAMPLE ONLY - HIGHLIGHTED FIELDS INDICATE NECESSARY INFORMATION

CERTIFICATE OF LIABILITY INSURANCE

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder in an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement of this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

PRODUCER

NAME OF INSURANCE COMPANY

ADDRESS

CITY, STATE, ZIP CODE

INSURED

NAME OF VENDOR

COMPANY NAME

ADDRESS

CITY, STATE, ZIP CODE

CONTACT NAME:

PHONE (A/C, No, Ext): FAX (A/C, No):

EMAIL ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC#

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER

NAME OF AGENT

AGENCY PHONE NUMBER

AGENCY EMAIL

INSURANCE CARRIER(S) NAMES

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MA HAVE BEEN REDUCED BY PAID

CLAIMS.

INSR

LTR TYPE OF INSURANCE ADDL

INSR

SUBR

WVD POLICY NUMBER POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

EACH OCCURRENCE $1,000,000

DAMAGE TO RENTED PREMISES

(Ea occurrence) $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $2,000,000

PRODUCTS - COMP/OP AGG $

COMBINED SINGLE LIMIT (Ea accident) $

BODILY INJURY (Per person) $

BODILY INJURY (Per accident) $

PROPERTY DAMAGE (Per accident) $

EACH OCCURRENCE $

AGGREGATE $

WORKERS COMPENSATION AND EMPLOYERS’ LIABILITY

ANY PROPRIETOR/PARTNERSHIP/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

(mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

WC STATUTORY LIMITS OTHER $

E.L. EACH ACCIDENT $

E.L. DISEASE - EA EMPLOYEE $

E.L. DISEASE - POLICY LIMIT $

GENERAL LIABILITY

GEN’L AGGREGATE LIMIT APPLIES PER:

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

POLICY PROJECT LOC

X

X

X

X POLICY NUMBER EFFECTIVE

DATE

EXPIRATION

DATE

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED AUTOS

HIRED AUTOS

SCHEDULED AUTOS

NON-OWNED AUTOS

UMBRELLA LIAB

EXCESS LIAB

DED RETENTION $

OCCUR

CLAIMS MADE

Y/N

MUST SHOW PROOF OF WC

AND DISABILITY INSURANCE ON

SEPARATE FORM

DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES

The City of Cooper City, its employees, agents, volunteers, independent contractors, successors and assigns, and other authorized representatives are included as Additional Insured on a primary and non-contributory basis, per the attached endorsement. The City shall be granted a Blanket Waiver of Subrogation per the attached endorsement. The Contractor waives, and the Contractor shall ensure that the Subcontractor and the Contractor's insurance carrier waives, all subrogation rights against the City, its employees, agents, volunteers, independent contractors, successors and assigns, and other authorized representatives for all losses or damages.

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE

THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.

City of Cooper City 9090 SW 50th Place Cooper City, FL 33328

AUTHORIZED REPRESENTATIVE

TWhite Highlight

TWhite Highlight

Certification Regarding Debarment, Suspension, Ineligibility and Voluntary

Exclusion

The local Proposer/Bidder hereby certifies that they have searched the records from the Excluded Party System List (EPSL) at this web link to verify that the named consultant/ contractor and sub-consultants/subcontractors do not have an active exclusion. Include all sub-consultants/subcontractors. (Click on ADVANCED SEARCH – EXCLUSION.)

Local Government (City/Town)

Title

Project Name

Date

Date

Date

Date

Printed Name of Authorized Representative

Signature of Authorized Representative

Project Number

Name of Consultant/Contractor

Name of Sub-consultant/Subcontractor

Name of Sub-consultant/Subcontractor

Name of Sub-consultant/Subcontractor

Use additional sheets as necessary.

https://www.sam.gov/portal/SAM/?navigationalstate=JBPNS_rO0ABXdcACJqYXZheC5mYWNlcy5wb3J0bGV0YnJpZGdlLlNUQVRFX0lEAAAAAQApdmlldzo2MjQwYTdkYy1mZmNhLTRjN2YtYmY4Yi02YWIxODllN2IxYjUAB19fRU9GX18*&portal:componentId=da4318dc-6b96-4dc1-be67-739ce150f67f&interactionstate=JBPNS_rO0ABXc3ABBfanNmQnJpZGdlVmlld0lkAAAAAQAWL2pzZi9kYnNpZ2h0U2VhcmNoLmpzcAAHX19FT0ZfXw**&portal:type=action

City of Cooper City

Contractor Due Diligence Affidavit

City Vendors and Contractors shall disclose the following as a condition of award for any contract that exceeds one million ($1,000,000.00) or that must be presented to the Commission for approval:

(1) Provide a list of all lawsuits in the five (5) years prior to bid or proposal submittal that have been filed against the firm, its directors, partners, principals and/or board members based on a breach of contract by the firm; include the case name, number and disposition;

(2) Provide a list of any instances in the five (5) years prior to bid or proposal submittal where the firm has defaulted; include a brief descriptin of the circumstances;

(3) Provide a list of any instances in the five (5) years prior to bid or proposal submittal where the firm has been debarred or received a formal email notice of non-complianec or non-performance, such as a notice to cure or a suspension from participating or bidding for contracts, whether related to the City of Cooper City or not.

All of the above information shall be attached to the executed affidavit and submitted to the Purchasing Division. The Vendor/Contractor attests to providing all of the above information, if applicable to the Purchasing Division.

Contract No. :

Federal Employer

Identification Number (FEIN):

Contract Title:

Printed Name of Affiant Printed Title of Affiant Signature of Affiant

Name of Firm Date

Address of Firm State Zip Code

Notary Public Information

Notary Public – State of County of

Subscribed and sworn to (or affirmed) before me this day of, 20___ by He or she is personally known to me or has produced identification

Type of identification produced

Signature of Notary Public Serial Number

Print or Stamp of Notary Public Expiration Date Notary Public Seal

Affidavit of Criminal Background Screening

AFFIDAVIT OF CRIMINAL BACKGROUND SCREENING

COMPANY/ORGANIZATION NAME: DATE:

COMPLETED AS:

Registered Vendor Special Event Vendor Advantage Marketing Other:

Permittee for: on Event Name Event Date

By signing this form, I am swearing or affirming that all individuals, including, but not limited to, employees, agents, volunteers, and independent contractors (collectively “Personnel”) employed or retained by the above named company/organization to provide goods or services on park property are not listed on at least one of these databases:

Florida Department of Law Enforcement Sexual Offender/Predator database: www.fdle.state.fl.us United States Department of Justice National Sex Offender Public Website: www.nsopw.gov

The information in this Affidavit is current and valid as of the date of completion. If additional Personnel are brought on to provide goods or services on park property, Affiant shall provide an updated Affidavit.

In the table below, please list all Personnel, including yourself, providing goods or services on park property. Include name, date of birth, and the date you checked the sexual offender databases listed on this form.

Name Birthdate Date Checked

(Use separate sheet of paper for additional names if necessary)

Signature of Affiant

State of Florida, County of Broward

Signed and sworn or affirmed to me this ____ day of ___________, 20___, by (Name of Affiant)

My commission expires SIGNATURE OF NOTARY PUBLIC, STATE OF FLORIDA

[ ] Personally known to me, or [ ] Provided identification

Type of identification:

DO NOT INCLUDE LICENSE NUMBER

(SEAL)

http://www.fdle.state.fl.us/ http://www.fdle.state.fl.us/ http://www.nsopw.gov/ http://www.nsopw.gov/

46{00624052.1 3451-0000000 }

DOMESTIC PARTNERSHIP CERTIFICATION FORM

THIS FORM MUST BE COMPLETED AND SUBMITTED AT TIME OF SUBMITTAL

FOR PROPOSER TO BE DEEMED RESPONSIVE

The Proposer, by virtue of the signature below, certifies that it is aware of the requirements of Section 2-

197.1 of the City of Cooper City’s Code of Ordinances, “Requirement for city contractors to provide equal benefits to domestic partners”, and certifies the following:

Please check only one below

1. The Proposer currently complies with the requirements of Section 2-197.1 of the City of Cooper City’s Code of Ordinances and provides benefits to domestic partners of its employees and the partners’ dependents on the same basis as it provides benefits to employees’ spouses and the spouses’ dependents

2. The Proposer will comply with the requirements of Section 2-197.1 of the City of Cooper City’s Code of Ordinances at time of contract award and provide benefits to domestic partners of its employees and the partners’ dependents on the same basis as it provides benefits to employees’ spouses and the spouses’ dependents

3. The Proposer will not comply with the requirements of Section 2-197.1 of the City of Cooper City’s Code of Ordinances at time of award

4. The Proposer does not need to comply with the requirements of Section 2-197.1 of the City of Cooper City’s Code of Ordinances at time of award because the following exemption applies:

Please check only one below The Proposer’s price bid for the initial contract term is $100,000 or less

The Proposer employs less than twenty-five (25) employees

The Proposer does not provide benefits to employees’ spouses or spouse’s dependents

The Proposer is a religious organization, association, society, or non-profit charitable or educational institution

The Proposer is a government entity

The Proposer cannot comply with the requirements of Section 2-197.1 of the City of Cooper City’s Code of Ordinances because it would violate the laws, rules or regulations of federal or state law or would violate or be inconsistent with the terms or conditions of a grant or contract with the United States or State of Florida. Indicate the law, statute or regulation .

(Attach explanation of its applicability)

47{00624052.1 3451-0000000 }

DOMESTIC PARTNERSHIP CERTIFICATION FORM (continued)

I, , of (Name) (Title) (Proposer)

Hereby attest that I have the authority to sign this notarized certification and certify that the above-referenced information is true, complete, and correct.

Signature Print Name

Personally Known: OR Identification Produced:

Type of Identification Produced:

(NOTARY SEAL)

STATE: COUNTY:

Sworn to (or affirmed) and subscribed before me this __________day of

, 20 , by: .

2607394v1

E-VERIFY/ CONTRACTOR/

VENDOR AFFIDAVIT

STATE OF ______________________

COUNTY OF ____________________

BEFORE ME, the undersigned authority, appeared __________________________, who first being duly sworn hereby swears or affirms as follows:

1. I make this affidavit on personal knowledge.

2. I am over the age of 18 years and otherwise confident to make this

Affidavit.

3. I am the _____________________________________ of

_________________________________________________ (the “Contractor/Vendor”).

4. I am authorized by __________________________________ to make this Affidavit on behalf of Contractor/Vendor.

5. Contractor/Vendor acknowledges that Section 448.09, Florida Statutes, makes it unlawful for any person to knowingly employ, hire, recruit, or refer, for private or public employment, an alien who is not duly authorized to work in the United States.

6. Contractor/Vendor acknowledges that Section 448.095, Florida Statutes, prohibits public employers, contractors, and subcontractors from entering into a contract unless each party to the contract registers and uses E-Verify.

7. Contractor/Vendor is in compliance with the requirements of Sections

448.09 and 448.095, Florida Statutes.

8. Contractor/Vendor understands it shall remain in compliance with the requirements of Sections 448.09 and 448.095, Florida Statutes, during the term of any contract with the City.

9. Contractor/Vendor’s subcontractors are in compliance with the requirements of Sections 448.09 and 448.095, Florida Statutes.

10. Contractor/Vendor shall ensure compliance with the requirements of

Sections 448.09 and 449.095, Florida Statutes, by any and all of its subcontractors.

11. Neither the Contractor/Vendor, nor any subcontractor of

Contractor/Vendor, has had a contract terminated by a public employer for violating

Section 448.095, Florida Statutes, within the year preceding the date of this Affidavit.

12. If the Contractor/Vendor, or any subcontractor of Contractor/Vendor, has a contract terminated by a public employer for any such violation during the term of any contract with the City, it shall provide immediate notice thereof to the City.

Signature of Affiant on behalf of Contractor/Vendor

By: __________________________________

As its: ________________________________

Dated: _______________________________

STATE OF ______________________

COUNTY OF ____________________

Sworn to (or affirmed) and subscribed before me by means of ☐ physical presence or ☐ online notarization, this _______ day of _________________________, 20___, by __________________________, on behalf of ____________________________, who is personally known to me or who has produced ___________________________ as identification.

Print Name: ___________________________ Notary Public of the State of Florida

My Commission Expires:

FAIR SUBCONTRACTING PRACTICES

Bidder/Proposer shall submit with the proposal a detailed statement of its policies and procedures (use separate sheet if necessary) for awarding subcontractors.

NO SUBCONTRACTORS WILL BE UTILIZED FOR THIS CONTRACT

Signature Date

FOREIGN (NON-FLORIDA) CORPORATION MUST COMPLETE THIS FORM

DEPARTMENT OF STATE CORPORATE CHARTER NO.

If your corporation is exempt from the requirements of Section 607.1501, Florida Statutes, YOU MUST CHECK BELOW the reason(s) for the exemption. Please contact the Department of State, Division of Corporations at (850) 245-6051 for assistance with corporate registration or exemptions. 607.1501 Authority of foreign corporation to transact business required.

(1) A foreign corporation may not transact business in this state until it obtains a certificate of authority form the Department of State.

(a) Maintaining, defending, or settling any proceedings.

(b) Holding meetings of the board of directors or shareholders or carrying on other activities concerning internal corporate affairs.

(c) Maintaining bank accounts.

(d) Maintaining officers of agencies for the transfer, exchange, and registration of the corporation’s own securities or maintaining trustees or depositories with respect to those securities.

(e) Selling through independent contractors.

(f) Soliciting or obtaining orders, whether by mail or through employees, agents or otherwise, if the orders

(g) Creating or acquiring indebtedness, mortgages, and security interests in real or personal property.

(h) Securing or collecting debts or enforcing mortgages and security interests in property securing the debts.

(i) Transacting business in interstate commerce.

(j) Conducting an isolated transaction that is completed within 30 days and that is not one in the course of repeated transactions of a like nature.

(k) Owning and controlling a subsidiary corporation incorporated in or transacting business within this state or voting the stock of any corporation which it has lawfully acquired.

(l) Owning a limited partnership interest in a limited partnership that is doing business within this state, unless such limited partner manages or controls the partnership or exercises the powers and duties of a general partner.

(m) Owning, without more, real or personal property.

(2) The following activities, among others, do not constitute transacting business within the meaning of subsection one (1):The list of activities of subsection (2) is not exhaustive.

(3) This section has no application to the question of whether any foreign corporation is subject to service of process and suit in this state under any law of this state.

Please check one of the following if your firm in NOT a corporation:

(I) Partnership, Joint Venture, Estate or Trust (II) Sole Proprieties of Self Employed

NOTE: This sheet MUST be enclosed with your bid if you claim an exemption or have checked I or II above, your firm will be considered a corporation and subject to all requirements listed herein.

SIGNATURE OF AUTHORIZED AGENT OF PROPOSER PROPOSER’S LEGAL NAME

FOREIGN COUNTRY OF CONCERN AFFIDAVIT

PERSONAL IDENTIFYING INFORMATION CONTRACT

Section 287.138, Florida Statutes, prohibits a Florida “Governmental entity” from entering into or extending contracts with any other entity whereby such a contract, or an extension thereof, could grant the other entity access to an individual’s personal identifying information if that entity is associated with a “Foreign Country of Concern.” Specifically, section 287.138(2), Florida Statutes, prohibits such contracts with any entity that is owned by the government of a Foreign Country of Concern, any entity in which the government of a Foreign Country of Concern has a “controlling interest, and any entity organized under the laws of or which has its principal place of business in a Foreign Country of Concern.

As the person authorized to sign on behalf of the Respondent, I herby attest that the company identified above in the section entitled “Respondent Vendor Name” is not an entity owned by the government of a

Foreign Country of Concern, no government of a Foreign Country or Concern has a principal controlling interest in the entity, and the entity has not been organized under the laws of or has its principal place of business in a Foreign Country of Concern.

I understand that pursuant to section 287.138, Florida Statutes, I am submitting this affidavit under penalty of perjury.

Respondent Vendor Name:

Vendor FEIN:

Vendor’s Authorized Representative Name and Title:

Address:

City: State: Zip Code:

Phone Number:

Email Address:

Certified By:

AUTHORIZED SIGNATURE

Print Name and Title:

Date:

1As defined in Section 287.138 (1)(d), Florida Statutes

2As defined in Section 287.138 (1)(c), Florida Statutes

3As defined in Section 287.138 (1)(a), Florida Statutes

H U M A N T R A F F I C K I N G A F F I D A V I T

In compliance with Section 787.06(13), Florida Statutes, this affidavit must be completed by an officer or representative of a nongovernmental entity that is executing, renewing, or extending a contract with the City of _______________ (the “Governmental Entity”).

The undersigned, on behalf of the entity listed below (the “Nongovernmental Entity”), hereby attests under penalty of perjury as follows:

1. I am over the age of 18 and I have personal knowledge of the matters set forth herein.

2. I am an officer or representative of_________________________, a non-governmental entity and I am authorized to provide this affidavit on behalf of Nongovernmental Entity)

3. Nongovernmental Entity, and any of its subsidiaries or affiliates, do not use coercion for labor or services, as those terms are defined in Section 787.06, Florida Statutes, as may be amended from time to time.

4. If, at any time in the future, Nongovernmental Entity does use coercion for labor or services, Nongovernmental Entity will immediately notify Governmental Entity and no contracts may be executed, renewed, or extended between the parties.

5. I have read the foregoing affidavit and confirm that the facts stated in it are true, and are made for the benefit of, and reliance by Governmental Entity.

Company: ___________________________________________

Authorized Signature: Date: _____________

Printed Name:

Title: _________________________________________________

STATE OF _________________

COUNTY OF _______________

The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this ____ day of ________________, 20____, by _________________________________, as _________________________ on behalf of the company/corporation. They ☐ are personally known to me or ☐ have produced _________________ as identification.

Notary Public Signature

(Affix Notary Stamp or Seal) Print, Type or Stamp Name of Notary:__________ My commission expires:______________________

NON-CONFLICT OF INTEREST STATEMENT

1. A. I am the of with a

[Insert Title] [Insert Company Name] a local office in and principal office in .

2. The entity hereby submits a proposal/offer in response to RFP 2024-6-FIN, BANKING SERVICES.

3. The AFFIANT has made diligent inquiry and provided the information in this statement affidavit based upon its full knowledge.

4. The AFFIANT states that only one submittal for this solicitation has been submitted and tendered by the appropriate date and time and that said above stated entity has no financial interest in other entities submitting a proposal for the work contemplated hereby.

5. Neither the AFFIANT nor the above named entity has directly or indirectly entered into any agreement, participated in any collusion or collusive activity, or otherwise taken any action which in any way restricts or restraints the competitive nature of this solicitation, including but not limited to the prior discussion of terms, conditions, pricing, or other offer parameters required by this solicitation.

6. Neither the entity nor its affiliates, nor anyone associated with them, is presently suspended or otherwise prohibited from participation in this solicitation or any contract to follow thereafter by any government entity.

7. Neither the entity nor its affiliates, nor anyone associated with them, have any potential conflict of interest because and due to any other clients, contracts, or property interests in this solicitation or the resulting project.

8. I hereby also certify that no member of the entity’s ownership or management or staff has a vested interest in any City Division/Department/Office.

9. I certify that no member of the entity’s ownership or management is presently applying, actively seeking, or has been selected for an elected position within City of Cooper City government.

10. In the event that a conflict of interest is identified in the provision of services, I, the undersigned, will immediately notify the City in writing.

By the signature(s) below, I/we, the undersigned, as authorized signatory to commit the firm, certify that the information as provided in this attachment is true and correct at the time of submission.

Signature of Affiant

Printed Name & Title of Affiant

OWNERSHIP DISCLOSURE AFFIDAVIT

1. If the contact or business transaction is with a corporation, the full legal name and business address shall be provided for each officer and director and each stockholder who holds directly or indirectly five percent (5%) or more of the corporation's stock. If the contract or business transaction is with a trust, the full legal name and address shall be provided for each trustee and each beneficiary. All such names and addresses are (Post Office addresses are not acceptable), as follows:

Full Legal Name Address Ownership

2. The full legal names and business address of any other individual (other than subcontractors, materialmen, suppliers, laborers, or lenders) who have, or will have, any interest (legal, equitable, beneficial or otherwise) in the contract or business transaction with the City are (Post Office addresses are not acceptable), as follows:

Signature of Affiant

Print Name

Date

SWORN STATEMENT PURSUANT TO SECTION 287.133 (3) (a), FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES

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 the CITY OF COOPER CITY, FLORIDA by:

(print individual’s name and title) for:

(print name of entity submitting sworn statement) whose business address is: 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: - -

2. 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 or 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 or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentations.

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 a plea of guilty or nolo contendere.

4. I understand that an “affiliate” as defined in Paragraph 287.133(1)(a), Florida Statutes, means:

a) A predecessor or successor of a person convicted of a 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 proposals 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, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity.

6. Based on information and belief, the statement that I have marked below is true in relation to the entity submitting this sworn statement. (Indicate which statement applies).

Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, not any affiliate of the entity, has been charged with and convicted of a public entity crime subsequent to July 1, 1989.

This 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 subsequent to July 1, 1989.

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 subsequent to July 1, 1989. 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 sworn 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 1 ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. 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.

Signature

Scrutinized Companies Affidavit

CERTIFICATION PURSUANT TO FLORIDA STATUTE § 287.135

I, , on behalf of, Print Name and Title Company Name certify that does not:

Company Name

1. Participate in a boycott of Israel; and

2. Is not on the Scrutinized Companies that Boycott Israel List; and

3. Is not on the Scrutinized Companies with Activities in Sudan List; and

4. Is not on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List; and

5. Has not engaged in business operations in Syria.

Submitting a false certification shall be deemed a material breach of contract. The City shall provide notice, in writing, to the Contractor of the determination concerning the false certification. The Contractor shall have ninety (90) days following receipt of the notice to respond in writing and demonstrate that the determination of false certification was made in error. If the Contractor does not demonstrate that the determination of false certification was made in error then the City shall have the right to terminate the contract and seek civil remedies pursuant to Florida Statute § 287.135.

Section 287.135, Florida Statutes, prohibits the City from: 1) Contracting with companies for goods or services in any amount if at the time of bidding on, submitting a proposal for, or entering into or renewing a contract if the company is on the Scrutinized Companies that Boycott Israel List, created pursuant to Section 215.4725, F.S. or is engaged in a boycott of Israel; and

2) Contracting with companies, for goods or services over $1,000,000.00 that are on either the Scrutinized Companies with activities in the Iran Petroleum Energy Sector List, created pursuant to s. 215.473, or are engaged in business operations in Syria.

As the person authorized to sign on behalf of the Contractor, I hereby certify that the company identified above in the section entitled does not participate in any boycott of Israel, is not listed on the Scrutinized Companies that Boycott Israel List, is not listed on either the Scrutinized Companies with activities in the Iran Petroleum Energy

Sector List, and is not engaged in business operations in Syria. I understand that pursuant to section 287.135, Florida Statutes, the submission of a false certification may subject the company to civil penalties, fees, and/or costs. I further understand that any contract with the City for goods or services may be terminated at the option of the City if the company is found to have submitted a false certification or has been placed on the Scrutinized

Companies with Activities in Sudan list or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector

List.

COMPANY NAME

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SIGNATURE