Fort Walton Beach Council agenda — 02-26-13--regular — reading text

I understand that " convicted" or " conviction" as defined in paragraph 287. 133( a)( b), Florida Statutes, means finding of guilt or a conviction of a public entity clime with or without an adjudication of guilt, in any federal or state trial court of records relating to charges brought by indictment or information after July 1, 1989, as a result of ajury verdict, nonjury trial, or entry of a plea of guilty or note contendere. 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 of shares constituting a controlling income among persons wben not for fair interest in another person, or a pooling of equipment or income among persons when not for fair market value under a length agreement, shall be a prima facie case that one person controls another person. A person who was knowingly convicted of a public entity crime, in Florida during the preceding 36 months shall be considered an affiliate. 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 the state or of the United States with the  6uipuel Mj Is Moo0 6uilsixg Jo luawaoeldoN £ t0-£ t Bil : ZOZZ) gonS N s)10aa - 018 £ CO-£ t auawgoelltl Mo a Reiilacenmtu MPxining Rwt Duck m Pon Walton t. a dng ITO 913 -013 0m n. legal power to enter into a binding contract for 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. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this swom statement. ( Please indicate which statement applies.) t' Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management of the entity, nor affiliate of the entity have been charged with and convicted of a public entity crime subsequent to July I, 1989. The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members, or agents who are active in 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. ( Please attach a copy of the final order.) The person or affiliate was placed on the convicted vendor list. There has been a subsequent proceeding before a hearing officer of the State of Florida, Division of Administrative Hearings. The final order entered by the hearing officer determined that it was in public interest ro remove the person or affiliate from the convicted vendor list. ( please attach a copy of the final order) The person or affiliate has not been placed or d nv" vendor list. ( Please describe any action taken by, or pending with, the Department ral Services.) yam '•" Signature) "` Date) J STATE OF: F%" gkt 0'/ 4 COUNTY OF: 6 Ua Sly PERSONALLY APPEARED BEFORE ME, the undersigned authority, who, after first day being sworn by me, affixed his/her signature at the space provided above on this /- of 2013, and is personally wn to mew or has provided as identification. ---" Notary Public My Connisysyit p3 . W i bit ,, p"te etnL° + Na" arlr 4,x Page I 1 of 28  6ulpueI mile yloo0 6ugsix3 ; o luawooeldaa £ GO- El. 1311 I ZOZZ) 4onS N 831380 - 0113 £( 0- E4 : lu8w4oellV Na aiuv CERTIFICATE OF LIABILITY INSURANCE VIM013 am Producer: Lion Insurance Company mm Certlnmte is lasu. dm. matter Pr brolma6Pn enly and mnan " rights 2739 U. S. Highway 19 N. Holiday, FL 34691 upon me[ erpmate" der. TMs CerBncata nom not amens, BRemd or alter the coyedee artordel by the III below. du 727) 938 -5562 Insurers Affording Cmerage a m NAIC P 1105 IMMIA: South East Personnel Leasing, Inc. & Subsldlade mauler A: Imulara: Lon Insurance lxrI 2739 U. S. Highway 19 N. InWearc Holiday, FL 34691 IlawarD muter E'. Coverages b I, ml9a W pinta ^mq iry : MMU2mBl4mlm P' u'r srymve[ la wbmapeam XHoencbmryaelrubamrywmb. memRrbr: NblMaYMi WItlMEP %DtlraelnlP btp[Ib PX H. Yma. eaiubtm, gtl mMlbonWxlipWtlei .epeipv2Ymlbebrnmryrawaeen ku'NEy pNdtlbma. Pwky E. yira4on Ome eOSRR AopL̀D Type of Insurance Policy Number Policyp88eNte LimilS MM00") MM) DD") GENERAL LLIBILfN Exhocurexe Commamial General Uebility pvrca. miwuam «msezlEF Claims Made 11 Occur umaol ved E, o Personal AEV Injury creme aggregate limI par Oewal ,u, rI P-- El Ptien LOC Roiurb- CdrygpApg AUTOMOBILE LIABILITY coneynesl . a o IAA A. 00m AMAoo Oedu" AI CmeCAUOS mPMm