Fort Walton Beach Council agenda — 03-12-13--regular — reading text

applicable) Federal Employer Identification Number ( FEIN) is 59- 1834097 ( If the entity has no FEIN, include the Social Security Number of the individual signing this swom statement). Brian Smith _ My name is and my relationship to the entity named above is Regional Director 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 ofany other state or with the United States, including, but not limited to, any proposal or contract for goods or services to he provided to any public entity or any agency or political subdivision of any other state N or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, N conspiracy, or material misrepresentation. aOv I understand that " convicted" or "conviction" as defined in paragraph 287. 133( a)( b), Florida Statutes, a 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 c information after July 1, 1989, as a result of ajury verdict, nonjury trial, or entry of a plea of guilty o or nolo contendere. a0` I understand that an " affiliate" as defined in Paragraph 287. 133( I)( a), Florida Statutes, means: 0 A predecessor or successor of a person convicted of a public entity crime ( or) 0M a An entity under the control of any natural person who is active in the management of the LL to entity and who has been convicted of a public entity crime. The term " affiliate" includes c 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 r0E n constituting a controlling income among persons when not for fair interest in another person, a 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. et Pg. Z02  PSV PNS P. 08 FEB - 04 - 2013 15: 25 15. 2. It Fort WAh andin ands I I understand that a " person" as defined in Paragraph 289. 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 v entity submitting this sworn statement. ( Please indicate which statement applies.) T y X Neither the entity submitting this swom statement, nor any officers, directors, executives, c partners, shareholders, employees, members, or agents who are active in management of the entity, N nor affiliate ofthe entity have been charged with and convicted of a public entity crime subsequent to m July 1, 1989. v m The entity submitting this swom statement, or one or more of the officers, directors, o executives, partners, shareholders, employees, members, or agents who me active in management of o the entity or an affiliate of the entity has been charged with and convicted of a public entity crime 0. subsequent to July 1, 1989. ( Please attach a copy of the final order.) 9 The person or affiliate was placed on the convicted vendor list. There has been a subsequent 3 proceeding before a hearing officer of the State ofFlorida, Division ofAdministrative Hearings. The a final order entered by the hearing officer determined that it was in public interest to remove the o person or affiliate from the convicted vendor list. ( Please attach a copy of the final order) ry The person or affiliate has not been placed on he convictS4 vendor list. (Please describe any 0 action taken by, or pending with, the Departm o Genet e esJ cn a t Iature w0 2/ 4/ 2013 0 Date) 0 STATE OF: Florida COUNTY OF: Escambia M a PERSONALLY APPEARED BEFORE ME, the undersigned authority, who, after first being sworn by me, affixed his/ her signature at the space provided above on this day w of \- 7ekxuc 2013, and is personally known to me, or has 9 provided tV I a as identification. a fJia DA r/. 0a 1CJt1 v Ntaryubli,- My Commission expires 1 p: 203  PAID FEB - 04 - 2013 15: 25 PSV PNS 15.2. 8" CTs Series 2- channel crown° ra HARMAN Features High powardensM. with all two -chanral models In TLC counter circuitry protects the Comprehensive way of Indkazors including a 2U chassis amplifier hom long -term exoessba heat by Power, Data and Bridge, along with Ready, subity and dynamically reducing the pain only Signal, Clip, Thermal add Fault for each Channel, Minot conatant- voltaga( 10V/ IOpVIt 40V200V)