FORM A-1
6.
Based on information and belief, the statement which I have marked below is true in relation to
the entity submitting this sworn statement. [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 the
management of the entity, nor any affiliate of the entity has 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 its 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.
___
The entity submitting this sworn statement, or one or more of its officers, directors,
executives, partners, shareholders, employees, members, or agents who are active in the
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. However, there has been
a subsequent proceeding before a Hearing Officer of the State of Florida, Division of
Administrative Hearings and the Final Order entered by the hearing Officer determined
that it was not in the public interest to place the entity submitting this sworn statement on
the convicted vendor list. [attach a copy of the final order]
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR
THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY
ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN
WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY
PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED
IN SECTION 287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANGE IN THE
INFORMATION CONTAINED IN THIS FORM.
_______________________________________
[signature]
Sworn to and subscribed before me this________________ day of __________________, 20_____.
Personally known_________________________________
OR Produced identification ________________________Notary Public - State of___________________
_______________________________________________My commission expires__________________
(Type of Identification)
(Printed typed or stamped Commissioned name of Notary Public)
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