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

If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement). My name is and my relationship to the entity named above isWi.-, Ae 3\' C I understand that 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. 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 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 I, 1989, as a result of a jury verdict, non -jury trial, or entry of a plea of guilty or nolo 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 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. I understand that a " person" as defined in Paragraph 287. 1330)( e), Florida Statutes, means any natural person or entity organized under the laws of the state or of the United States with the  Md le good Bugs!xg jo luawaoeldaa EI,o- El. 1311 c ZOZZ) uoponrlsuoD gol! 4S - GIB £ t0- E[ 7uewgoelltl „ n M a ITB NI3 013 - Replacement of heisting Soar Docket Fort Wilma Lending yYUN o. 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 axe 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 sworn statement. ( Please indicate which statement applies.) LNeither 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 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 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 onvicted vendor list. ( Please describe etfeml SeCryjylces.) any action taken by, or pending with, the Department G Signature) Date) STATE OF -V- Y f- COUNTY OF: Ct iVi— A1G PERSONALLY APPEARED BEFORE ME, the undersigned authority, who, after first being sworn by me, affixed hi" m signature at the space provided above on this I?) day of ' 1' 7e ` l-L , 2013, and is personally known to me, or has provided as identification.{ \ ( 6 Notary Public My Commission expires- N'> q,.ii JENNY DIANE MALLIN MY COMMISSION Fso5 saS EXPIRES January 12, 2015 MJIaMat69 Flw1a, NtlhMmM.com Page 11 of 28  Md to 4000 BupslX3 ; o tuawooeldoM £ LO-£ l 1311 : ZOZZ) uopongsuoD p0114S - 418 £ LO-£ t quawpoel3V vv rr DATE IMASE. YYYY1 CERTIFICATE OF LIABILITY INSURANCE 0210812013 aa T HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORM LTIO! PRODUCER UU HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OF lili 124 E MIRACLE STRIP PKWY STE 206 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW MARY ESTHER FL 32669 INSURERS AFFORDING COVERAGE _ NAIC# INSURES INSURER A: REPUBLIC VANGUARD INS CO INSUREaa SHILOH CONSTRUCTION LLC INSURER c: 1296 BEVERLY ST INSURER D. FT WALTON BCH FL 32547 COVERAGES COVERAGES THETHE POLICIESPOLICIES OFOF INSURANCEINSURANCE LISTEDLISTED BELOWBELOW HAVEHAVE BEENBEEN ISSUEDISSUED TOTO THETHE INSURED INSURED NAMEDNAMED ABOVEABOVE FORFOR THETHE POLICYPOLICY PERIODPERIOD INDICATED.INDICATED. NOTWITHSTANDING NOTWITHSTANDING ANYANY REQUIREMENT,REQUIREMENT, TERMTERM OROR CONDITION CONDITION OFOF MYMY CONTRACTCONTRACT OROR OTHEROTHER DOCUMENTDOCUMENT WITHWITH RESPECTRESPECT TOTO WHICHWHICH THISTHIS CERTIFICATECERTIFICATE MAYMAY BEBE ISSUEDISSUED OROR MAYMAY PERTAINPERTAI , N, THETHE INSURANCEINSURANCE AFFORDEDAFFORDED BYBY THETHE POLICIES POLICIES DESCRIBED DESCRIBED HEREINHEREIN ISIS SUBJECTSUBJECT TOTO ALLALL THETHE TERMS,TERMS, EXCLUSIONSEXCLUSIONS ANDAND CONDITIONSCONDITIONS OFOF SUCHSUCH POLICIES.POLICIES. AGGREGATEAGGREGATE LIMITSLIMITS SHOWNSHOWN MAYMAY HAVEHAVE BEENBEEN REDUCED REDUCED BYBY PAIDPAID