Fort Walton Beach Council agenda — 09-10-13--regular — reading text

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 bid or contract for goods or services to be provided to any public entity or any agency or political subdivision of my other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 5. 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 a jury verdict, non -jury trial, or entry of a plea of guilty or nolo wntendere. 6. 1 understand that an " affiliate" as defined in Paragraph 297. 133( 1 Ha), Florida Statutes, means: 1. A predecessor or summer of a person 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. The teen " affiliate" includes those officers, directors, executives, partners, shareholders, employees, page is orm 8 Aed M-EL ddN to paeMV : 405Z) Dll' suollnloS uaaa6aaA3. lesodord PI13 gl0-CL d-AN quawgoeHtl A a Pay and Cle,sifiaalion study fa the City or FUn Walmn Each. FR. RFP 13 -018 Y' U 6 RFP# 13 -018 Public Entity Crimes Statement —Pg 2 or3 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 3b months shall be considered an affiliate. T 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 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 n 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.) Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members, or agents who are active in managemem 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 Hearing. 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 end' g with, the Department of General Services.) rL' 57 " Signature) vp. tfhreet- tSa ' t.( ig Si U. Company) Date: % I1111 5 Page 19oHA  V Red 81, 0- CL dda to PJeamy : YOSZ) 311' suopnloS uaaJ6aaA3 - lesodoad Pig M-CL ddb : luawyaeUtl P ut a Pay and Clmlr Gon SNdyforme Citynr Pmt Walton B, ahjl- RFP 13 -0I8 YmY a RFP # 13 -019 Public Entity Crimes Statement —Pg 3 of STATE OF F1' COUNTY OF ORV Yi PERSONALLY APPEARED 13EFORE ME, the Bndersigned authority, who, a first being s rn by me, affixed his/ her signature at the space provided above o this = day of UQA. 2013, and is Personally town to m or has provided driver' s license/military id) as identification. i J 16 yPublic My Commission expires: / O / Z PIIBUC End of Attachment D sul C" CF a EE11lESb r E4*" 1y0yypl5 hp 20 orsa  M dPM- d S 145 AlOf " 31NI1 ltloo 11 £ 7 31V0 3no 9 i. 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