Fort Walton Beach Council agenda — 01-24-12 regular — reading text

x implementation of Paragraphs 1 through 5, JQ ro Check one: As the person authorized to sign this statement. I eerily that this Flan complies as fully with above requirements K a As the person authorized to sign this statement, this firm does not comply fully ro F with the above requirements. m NAME OF BUb NESS: yltG G )' IEk PRI SE< N BY ATURE SIGNATURE E NAME & TITLE. TYPED OR PRINTED: t R, o PagePage 99 ofof 2727 PxItMPxItM Pg.Pg. 5858  8. 3. a PUBLIC ENTITY CRIME FORM (3 pages) - ITB R 12 -008 o 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 avN OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. c_ m I. This sworn statement is submitted with Bid. Proposal or Contract M" ZV 0C r' v E/t( YlL 6JkRttk4it SiE'f't %! lutlJ[ l) + Rs' Lv Lc- 2 This sworn statement is submitted whose business address is: Z$ e",Z le 6 Oi Vt` l Ar a% 3z5'c3 and ( if applicable) Federal Employer Identification Number FEIN) isS±Zme.e4s( If the entity has to FEIN. include the Social Security Number of m00N_ the individual signing this sworn statement: mr v 3. My name is T2 +- L and my relationship to Elie entity named above VICE - R( S VEN', 3 a 4. 1 understand that a " public entity crime' as defined in Paragraph 287. 133( a)( g). rm 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, anv bid 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 vN antitrust, fraud. thell, bribery. collusion, racketeering, conspiracy. or material P- misrepresentation. 5, 1 understand that " convicted" or " conviction" as defined in paragraph 287. 173( 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 stale trial court of records relating to charges brought by indictment or information atler July 1, 1989, as a result of a 0 jury verdict, non -jury trial, or entry rife plea of guilty or nolo eomendere. O 6. 1 understand that an " affiliate" as defined in Paragraph 287. 1330U( a), Florida ma Statutes, means: mF m A predecessor or successor ofa person convicted of a public entity crime: or moN 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 term " affiliate" includes those officers, directors, executives, partners. caE shareholders, employees, members. and agents who are active in the management of an affiliate. The ownership by one of shares constituting a ZM 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 Page 10 of 27 Packet Pg. S9  8. 3. a I IS kI_ OUY t . pnni. I dd ` 1(. yl H yl n_.. ( I I Bk 12- 008 Public Entity Crimes Statement —Pg2 of No0 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. amN 7. 1 understand that a " person" as defined in Paragraph 287. 133( 1)( e), Florida c 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 tranwct business with a public entity. The term " person' includes those officers, directors. exeaniveS, partners, shareholders, employees members and agents who are active n rad management of an entity. 0 8. Baser) on information and belief. the statement which I have marked below is true N in relation to the entity submitting this sworn statement, ( Please indicate which statement M applies.) / a Neither the entity submitting this sworn statement. nor any officers, directors, executives, partners, shareholders, employees, members, or 3 a 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 rN 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 v agents who are active in management of the entity or an affiliate of the a 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) Wcry The person or affiliate was placed on the convicted vendor list. There has x 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 tite person or affiliate from the convicted vendor list. ( Please attach a copy of the final order) The person or affiliate has not be p a on the convicted vendor list.