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

NAME & TITLE, TYPED OR PRINTED: ia h J p / 6U Page 9 of 28  M=I In 4000 Bupslx3 ; o tuawaoeidaa Et0 -Et 911: ZOZZ) Out Bu110e11u03 WOW - 4113 £ lO -EI : lu8wg0e11V m vr. a h8 At3n13 Replxement of Gziaina tl" nocl m Fan Walbn dina YaU SECTION 2. 6 PUBLIC ENTITY CRIME FORM —RFP 13- 613 a SWORN STATEMENT UNDER SECTION 287. 133 ( 3) ( A) FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. This sworn statement is submitted with Proposal, Proposal or Contract This sworn tatement is submitted by._ 112 11/lG,o/ i wbose business address is ! / a l a r.' lJli'C.r S% C en 4 and ( if applicable) Federal Employer Identification Number ( FEIN) is 59 -34" gAA (If the entity has no FEIN, include the Social Security Number of the individual signing this swom statement). My name is C t1_ K jGL and my relationship to the entity named above is JZCo 2 C —Mw m: cE.sr ` Fs Jj I understand thin a " public entity crime" as defined in Paragraph 287. 133( a)( 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 with the United States, including, but not limited to, any proposal 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. 1 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 crime 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, non -jury Vial, or entry of plea of guilty or note contendere. I understand that an " affiliate' as defined in Paragraph 287. 133( i)( 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 when 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. 1 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  Md m Iona Bupslx3 Jo luawaaeldea £ t0-£ t ail: ZOZZ) ' oul 611113eAU00 WrJW - al9 Et0-£ t : luamgoelly o aai a ITS 413 -013 apl tofExisting Boat Docket Fwt Wskm Landing YaU legal power to enter into a binding contract for provision of goods or services let by a public a entity, or which otherwise transacts or applies to transact business with a public entity. The tern 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 1 have marked below is true in relation to the entity submitting this sworn statement. ( Please 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 management of the entity, nor affiliate of the entity have been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this swom 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 to 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 on the convicted vendor list. ( Please describe any action taken by, or pending with, the Department of General Services.) lfwla Signature) a - s' -13 Date) STATE OF: 3mit x-d- COUNTY OF: i rL Ucu"CL PERSONALLY APPEARED BEFORE ME, the undersigned authority, who, aft/.eerr first being sworn by me, affixed his/ her signature at the space provided above on this O' day of YPX)4 rwtr 2013, and "" is personally known to me, or has 1 provided Floncl?(, k.. ynL{cfrtlFtczi' ta- asidentitiration. Notary Public I' My Commission expires SUSAN 0 rf 1', kj Oj6 NOTARY AUDUC y STATE OF PLOT" CommAEE19I623 Explms 4/22!2016 Page I I of 28  Md le Hood 6ups1x3 ; D luewooeidey £ LO-£ L 811: ZOZZ) ' Oui 6UI10eAIUO3 MW - 010 £ LO -£ l lUDwyoellV n Rd CERTIFICATE OF LIABILITY. INSURANCE 2/ 7/ 2013 " x ERTIFlCATE IS ISSUED AS A NATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE GERII" CATE HOLDER. THIS ICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ccn mnAYn no IMAI IYANCP nnss NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUREFUS), AUTHORRED d may require Twin Rivera Insurance, Inc. 306 H New Hawn Avenue INSURED MO13 Contraotiav, IAt. 1121 Peachtree BE THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED Tb THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. CERTIFICATENOTMTHSTANDING MAY BE ISSUED ORANY MAYRBOUIREMENT. PERTAIN, THETERM OR CONDITION INSURANCE OF BY AFFORDED ANYTHE CONTRACT POLICIESORDESCRIBED OTHER DOCUMENT HEREIN ISVAIH RESPECTALL SUBJECT TO ALL THEE TTERMS, THIS EWILU910NSAND CONDITIONS OF SUCH POLICIES, LINOS SHOWN MAY HAVE BEEN REDUOED BY PAID CLAIMS. H POD