Marshall Williamson Bid Forms Pages 27-35r°- being first duly sworn, deposes and states that:
(l) Fie She/They islare the
(Owner, Partner, Officer, Representative or Agent) of
(i% --the Respondent that has submitted the
attached Proposal;
Sign d, sealed and delivered in the presence of:
By:
Witness
tpeepeO2 -18- i 3 Page 27 of 72
STATE OF-FLeRfE)A
!Dc'L't
C'niomas F. Pepe, 2011-2011 All rights reserved.
7/11/13/13
.1
g.# O w
The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State Statutes.
Respondents must disclose with their Proposals, the name of any officer, director, partner, associate or agent who
is also an officer or employee of the City of South Miami or its agencies.
AMID
TAIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
#FFICIAL AUTHORIZED TO ADMINISTER OATHS.
his sworn stat
su itted to
nt name • the public entity]
ffy
,print i ra al's name and title]
for
[print name of entity submitting sworn statement]
business address is
.. . ..... . ....
and (if applicable) its Federal Employer Identification Number (FEIN) is 'SCI-2-4 (If the
entity has no FEIN, include the Social Security Number of the individual signing this sworn statement:
3. 1 understand that "convicted" or "conviction" as defined in Paragraph 287.133 (1) (b), Florid
S=tes means a 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 record relating to charges brought by indictment or
information after July 1, 1989, as a result of a jury verdict, non-jury trial, or entry of a plea of guilty or
no lo contendere.
4. 1 understand that an "affiliate" as defined in Paragraph 287.133 (1) (a), Florida 5taLgtes, 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
0 Thomas F. Pepe, 2011-2013, All rights reserved. Page 29 of 72
7/11/13/13
interest in any 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.
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.
Immaliff �. -- iAGzJZL=#=-§ -
--I
I Thomas F. Pepe, 2011-2013, All rights reserved.
C
7/11/13/13
My commission expires
,overnewQf notary public)
4
- �C,-�
7
Cyr
Whenever two or more Bids or Proposals which are eaual vAt
_7VITU'al alwWw1fiblIT11b 11if ult� procaTement ot commootties or contractual services, a Bid or
proposal received from a business that certifies that it has implemented a drug-free workplace program shall be
given preference in the award process. Established procedures for processing tie Bids or proposals shall be
followed if none of the tied vendors have a drug-free workplace program, In order to have a drug-free workplace
program, a business shall:
Page 31 of 72
C Thomas F. Pepe, 2011-2013. All rights reserved.
7111/13/13
to comply with such act or regulation,
• 0 •
Witness
BY:
Name a 'ej� -�3 k
no M;
Oc Thomas F. Pepe, 2011-2011 All rights reserved,
7/11/13/13
LIST OF PROPOSED SUBCONTRACTORS AND PRINCIPAL SUPPLIERS
within five (b) business days after Bid Opening.
69 Thomas F, Pepe, 2011-2013. All rights reserved. Page 33 of 72
7/11/13/13
MN�
individually and • behalf of IaVV;t"2k'C
("Firm")ha—ve'-I�ame of RePresentative COMPanyll/endor/Entity read the City of South miami ("City")'s Code of Ethics,
Section 8A- I of the City's Code of Ordinances and I hereby certify, under penalty of perjury that to the best of my
knowledge, information and belief:
(1) neither I nor the Firm have any conflict of interest (as defined in section 8A- 1) with regard to the contract or
business that 1, and/or the Firm, am(are) about to perform for, or to transact with, the
City, and
(2) neither I nor any employees, officers, directors of the Firm, nor anyone who has a financial interest greater
than 5% in the Firm, has any relative(s), as defined in section 8A- 1, who is an employee of the City or who is(are)
an appointed or elected official of the City, or who is(are) a member Of any public body created by the City
Commission, i.e,, a board or committee of the City, (while the ethics code still applies, if the ersol
.J.-A agat
W - W. Ulubt: MJU HaVe a Tinanciat interest in the Firm.]
(3) neither I nor the Firm, nor an one who has a financial interelt A7&
�-1116010116461 I I k-1,
Lo k-I N
firlsof r. 1 mitt K.74ILgill
(5) 1 and the Firm further agree not to use or attempt to use any knowledge, property or resource which may
come to us through our position of trust, or through our performance of our duties under the terms of the
contract with the City, to secure a special �rivilege, benefit, or exemption for ourselves, or others. W i MW i
P
O Thomas F. Pepe, 2011-2013. All rights reserved. . age 3 of 72
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benefit or for the personal gain or benefit of any other erson or business entivy. outsidg- jof rjp�j
, 11111311111-IM '�fflff-W.
(9) 1 and the Firm agree that we are obligated to supplement this Verification Form and inform the City of any
change in circumstances that would change our answers to this document. Speccally, after the opening of any
res,jonses to a solicitation- I and the Firm
all R * elated Parties who have also responded to the same solicitation and to disclose the relationship of those
parties to me and the Firm.
IMITZIMIMMORT M*e F-34-MYSIM
may ue ronst Wrey
znd sub ect to action bi the iami-Di tjj
11 066
'I M111golour-14MOMI F 0 1 1 F
Thomas F. Pepe, 2011-2013. All rights reserved. Page 35 of 72
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