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

N FEIN) is 59- 326775'X1£ the entity has no FEIN, include the Social Security Number of the individual signing this mom statement inF a 1 My time is Howard Holley and my relationship to 3 the entity named above is President — Owner 4. I understand that a " public entity crime" as defined in Paragraph 287. 133( a)(g). nN Florida Statutes, means a violation of my state or federal law by a person with respect to and directly related to the transaction of business with my public entity or with an agency or political subdivision of my other state or with the United States, including, but not limited to, my bid or contract for goods or services to be provided to my public entity or UmNo my agency or political subdivision of airy other state or of the United States and involving amm st, fraud, misrepresentation. theft bribery, collusion, racketeering, conspiracy, or material U0COc 5. I understand that " convicted" or " conviction' as defined in paragraph EN 287. 133( a)( b), Florida Statutes, means finding of guilt or a conviction of a public entity U crime with or without an adjudication of guilt, in my federal or state trial coon of records J relating to charges brought by indictment or information after July 1, 1989, as a result of a y jury verdict, non jury trial, or entry of a plea of guilty or nolo comendere. a O 6. I understand that m " affiliate" as defined in Paragraph 287. 133( 1)( a), Florida a States mews: in 1. A predecessor or successor of a person convicted of a public entity crime; or 0 2. An entity under the control of my natural person who is active in the management of the entity and who has been convicted of a public entity crime. c The term " affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the E management of an affiliate. The ownership by one of shares constituting a NU controlling income among persons when not for fair interest in mother person, a or a pooling of equipment or income among persons whim not for fair market value under a length agreement, shall be a prima facie case that one person Page 10 of 27 Packet Pg. 71  8. 3. b 1fit 112- 410.4 U" n, mrvod 0, M,- 1 SIM ROD., 11 ITB# 12 -008 Public Entity Crimes Statement —Pg 2 of 3 controls soother person. A person who was knowingly convicted of a public entity 0No Z crime, in Florida during the preceding 36 months shall be considered an affiliate. fn 7. I 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 0 United States with the legal power to enter into a binding contract for provision of goods a 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 zda o' management of an entity. m Based on information and belief, the statement which I have marked below is true 8. in relation to the entity submitting this mom statement. ( Please indicate which statement 00N_ applies.) mr a Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members, m 3 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 nN 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 UNO agents who are active in management of the entity or an affiliate of the 0 entity has been charged with and convicted of a public entity crime U subsequent to July 1, 1989. ( Please attach a copy of the final order) 0 The person or affiliate was placed on the convicted vendor list There has aEN been a subsequent proceeding before a hearing officer of the State of v Florida, Division of Administrative Hearings. The final order entered by J 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 0 the final order) M 0 rca 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 mr General Services.) o Signature) CHAMPION CONTRACTORS INC. Date: Company) I3 December 2011 c0NtmE Page 11 of 27 Packet Pg. 72  8. 3. b i' I'D d] LMifi dal 0 d d StIIII Ra - 9b ITB# 12- 008 Public Entity Crimes Statement —Pg 3 of 3 o0 a STATE OF FLORIDA COUNTYOF OKATnogA Nmc_ PERSONALLY APPEARED BEFORE ME, the undersigned authority, who, after first being swum by me, affixed hislhhea signature at the space provided above on this J3 . day of ham. 2011, and is personally Imovm to me, or has provided aGrmc driver' s license/military id) as identification. G t o4 y Public My Commission expires: ( I I b )aDla Nnlary PUbliO alelp 0 Fl Ma S Cpllanie HO Wet 5 My eommiseion nOBa] B89