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

m I,, I— fully with above requirements. m04 As the person authorized to sign this statement, this firm does not comply fully with the above requirements. c NE NAME OF BUSINESS: ;— a-f_74 ( Lit' L' L__ zNa SI NATURE n NAME & TITLE. TYPED OR PRINTED: Page 9 of 27 Packet Pg. 85  8. 3. c dd IRUn„ D ...m IIR- 1dA4tN PUBLIC ENTITY CRIME FORM ( 3 pages) - ITB k 12 -008 SWORN STATEMENT UNDER SECTION 287. 133 ( 3)( A) FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES 0N0 THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC ivn OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. c This sworn statement, is submitted or Contract 4 1 T 6. 12- rV7 a 2. This sworn statement is t0 o' whose business address is: 6 and ( if applicable) Federal Employer Identification Number 00N FEIN) is ( If the entity has no FEIN, include the Social Security Number of M the individual signing this sworn statement: v 3. My name is yp^,.. l.?/I dj and my relationship to 3 a the entity named above is m 4. 1 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 NN and directly related to the transaction of business with any public entity or with an agency u or political subdivision of any other state or with the United States, including, but not o limited to, any 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 3 antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. r0L Ja 5. 1 understand that " convicted" or " conviction" as defined in paragraph 0 287. 133( a)( b), Florida Statutes, means finding of guilt or a conviction of a public entity 0 crime with or without an adjudication of guilt, in any federal or state trial court of records o- to relating to charges brought by indictment or information after July I, 1989, as a result of a m jury verdict, non jury trial, or entry of a plea of guilty or nolo contendere. r 0 6. 1 understand that an " affiliate' as defined in Paragraph 287. 133( I)( a), Florida N Statutes, means: 1. A predecessor or successor of a person convicted of a public entity crime: or EE m 2. An entity under the control of any natural person who is active in the a 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 Page 10 of 27 Packet Pg: 86  8. 3. c Smut Itnain- porn', L, I; InIt j ITB# 12 -008 Public Entity Crimes Statement— Pg 2 of 3 NO controls another person. A person who was knowingly convicted of a public entity o° crime, in Florida during the preceding 36 months shall be considered an affiliate. Nd 7. 1 understand that a " person' as defined in Paragraph 287. 133( I)( e), Florida M 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 am or services let by a public entity, or which otherwise transacts or applies to transact a business with a public entity. The term " person' includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active n td management of an entity. 8. 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.) 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 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 m 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. m00N en t of Please describe any action taken by, or pending with, the De C General Services.) E Signature) rN Company) Date: /? Z?// Page I I of 27 PaekeEPg. 87.  8. 3. c L. Iit ui, I liyii — Dm, _ IIt: rt a @k ITB# 12 -008 Public Entity Crimes Statement— Pg 3 of 3 STATE OF FLORIDA COUNTY OF UK46e,5d PERSONALLY APPEARED BEFORE ME, the undersigned authority, who, after first being swor by me, affixed his /her signature at the space provided above on this oe day of oetbGf/ , 2011, and is personally known to me, or has provided omapf L3, / usy ( driver' s license /military id) as identification. t l r t Notary. Pul& My Commission expires: DONMtMBE