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SWORN STATEMENT PURSUANT TO SECTION 287.133 (3)(A),

FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES

THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIALS/AUTHORIZED TO ADMINISTER OATHS.

1.  This sworn statement is submitted to

                                                                                                          (print name of public entity)

    by

                                           (print individual's name and title)

    for

                                           (print name of entity submitting sworn statement)

    whose business address:

    And (if applicable its Federal Employer Identification Number (FEIN) is:  

    (If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement):  

2.

I understand that a "public entity crime" as defined in Paragraph 287.33(1)(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 or any other state or of the United States.  Including, but not limited to, any bid contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.

3.

I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes, means a finding of guilt or a conviction or a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, nonjury trial, or entry or a plea of guilty or nolo contender.

4.

I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes, means:

a.

A predecessor or successor of a person convicted of a public entity crime: or

b.

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, shareholders, employees, members, and agents who are active in the management of an affiliate.  The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that one person controls another person.  A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate.

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