attachement a pages 49 to 58b) 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,
5. 1 understand that a "person" as defined in Paragraph 287:133(1) (e), Florida Statues,
means any natural person or entity organized under the laws of any state or of the
United States within the legal power to enter into a binding contract and which bids or
applies to bid on contracts for the provision of goods or entity. The term "person"
includes those officers, executives,; partners, shareholders, employees, members, and
agents who are active in management of an entity
6. Based on information and belief, the statement which i have marked below is true in relation to
the entit submitting this sworn statement. (Please indicate which statement applies.)
Neither the entity submitting sworn statement, nor any of its officers, director,
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 the
management of the entity, or an affiliate of the entity, or an affiliate of the entity had been charged
with and convicted of a public entity crime subsequent to July 1, 1989, AND (please indicate which'
additional statement applies:
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, nor any affiliate of the entity has been charged with and convicted of a
public entity crime subsequent proceeding before a Nearing Officer of the State 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).
�y • s
FLORbA 4 PUBLIC CRIMEA
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A
NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER
OATHS
1. This form statement is submitted to ! ? Cl 0,
by
(Print individual's name and title)
For G. C' cr d e ,[
(Print name of entitysubm Bing sworn statement)
whose business address 0 u-) 6 f C 199/ �7tV
and if applicable its Federal Employer Identification Number (FEIN) is o t 7p M If the entity
has not FEIN, include the Social Security Number of the individual signing this sworn statement.
2. t understand that a "public entity crime" as defined in paragraph 287.133(1)(g), Florida Statues,
means a violation of any state or federal law by a person with respect to an directly related to
the transactions of business with any public entity or with an agency or political subdivision of
any other state or with the United States, including, but not limited to any bid or contract for
goods or services to be provided to public entity or agency or political subdivision of any other
state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering,
conspiracy, or material misinterpretation.
3. "1 Understand that "convicted" or "conviction" as defined in Paragraph 287.133(1) (b), Florida
Statutes, means a finding of guilt or a conviction of a "public entity crime, with or without an
adjudication of guilt, in an 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 nolo contenders.
I 4. 1 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
RESPONSIBILITY AT`
As required by Executive Order 12549, Debarment and Suspension, and
implemented at 28 CFR Part 67, for prospective participants in primary covered
transactions; as defined at 28 CFR Part 67 Section 67.510-
1. The applicant certifies that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared
ineligible, sentenced to a denial of Federal benefits by a State or Federal court, or
voluntarily excluded from covered transactions by any Federal department or
agency;
(b) Have not within a three -year period preceding this application been convicted of or
had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(f=ederal, State, or local) transaction or contract under a public transaction; violation
of Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving
stolen property;
(c) Are not presently indicted for or otherwise criminally or civilly charged by a
governmental entity (Federal, State, or local) with commission of any of the offenses
enumerated in paragraph (1)(b) of this certification; and
(d) Have not within a three -year period preceding this application had one or more
public transactions (Federal, State, or local) terminated for cause or default; and
2. Where the applicant is unable to certify to any of the statements in this
certification, he or she shalt attach an explanation to this application.
L E CJ 7d2G r °Y ?7
Nam; of RFrlrio> �'
6fficlai Address (including Zip Code)
w� a
MEMO
NOTICE OF REQUIREMENT
CLEAN WATER, CLEAN AIR, EXECUTIVE ORDER (E.o) 11738
AND EPA REGULATIONS PROVISION
This agreement is subject to the requirements of the Clean Air Act, as amended, 42 USC 1857 et
seq., the Federal Pollution Control Act, as amended, 33 USC 1251 at seq. and the regulations of the
Environmental Protection Agency with respect thereto, at 40 CFR Part 15, as amended from time to
time:
The Contractor and any of its subcontractors for work funded under this Agreement which is in excess
of $100,000, agree to the following requirements:
19
1. Any facility to be utilized in performance of this proposed contract has ( ); has not
( ) been listed on the Environmental Protection Agency List of Violating Facilities;
2. The contractor or any of its subcontractors agree to comply with all the requirements of
Section 114 of the Clean Air Act, as amended (42 ISC 1857c -8) and Section 308 of the
Federal Water Pollution Control Act, as amended, ;(33 USC 1318) relating to
inspection, monitoring, entry, reports, and information, as well as all other requirements
specified in said Section 114 and Section 308, and all regulations and guidelines
issued thereunder;
3. The contractor or any of its subcontractors agree that, as a condition for the award of
the contract, prompt notice will be given of any notification received from the Director,
Office of Federal Activities, Environmental Protection Agency (EPA) indicating that a
facility utilized or to be utilized for the contract is under consideration to be listed on the
EPA list of Violating Facilities; and
4. The Contractor or any of its subcontractors agree that he will include or cause to be
included the criteria and requirements in paragraph 1 through 4 of this section in every
nonexempt sub- contract and that the Contractor will take such action as the
Government may direct as a means of enforcing such provisions.
Blame of Bidder
Authortz Signature _
Date
A Certification of Nonsegregated Facilities, as required by the May 9, 1967, order (32 FR,
7439, May 19, 1967) on Elimination of Segregated Facilities by the Secretary of Labor, must
be submitted prior to the award of a subcontract exceeding $10,000, which is not exempt from
the provisions of the Equal Opportunity Clause. The certification may be submitted either for
each subcontract or for all subcontracts during a period (.e., quarterly, semiannually,
annually ).
Note: The penalty for making false statements in offers is prescribed in 18 U.S.C. 1001
Title: ff
CERTIFICATION OF NONSEGREGATED FACILITIES
1. "Segregated facilities," as used in this provision, means any waiting rooms, work areas;
rest rooms and wash rooms, restaurants and other eating areas, time clocks, locker
rooms and other storage or dressing areas, parking lots, drinking fountains, recreation
or entertainment areas, transportation, and housing facilities provided for employees;
that are segregated by explicit directive or are in fact segregated on the basis of race,
color, religion, or national origin, because of habit, local custom, or otherwise:
Z By the submission of an offer, the bidder certifies that it does not and will not maintain
or provide for its employees any segregated facilities at any of its establishment, and
that it does not and will not permit its employees to perform their services at any
location under its control where segregated facilities are maintained. ' The bidder
agrees that breach of this certification is a violation of the Equal Opportunity clause of
the contract.
3. By submission of the bid, the bidder further agrees that (except where it has obtained
identical certifications from proposed subcontractors for specific time periods) it will:
a. Obtain identical certifications from proposed subcontractors before the award of
subcontracts under which the subcontractor will be subject to the Equal
Opportunity clause;
b. Retain such certifications in its files; and
c. Forward this certification and the attached NOTICE TO PROSPECTIVE
SUBCONTRACTORS OF REQUIREMENT FOR CERTIFICATION OF
NONSEGREGATED FACILITIES to proposed subcontractors.
d. By commencing performance of the Contract work, the selected contractor
certifies to the Nonsegregated Facilities provisions above.
Note: The penalty for making false statements in offers is prescribed in 18 U.S.C.
1001 '-1/111
Title:
Date: / '30 crt
G
Business. Address: 1;2 C 0 LA-11 C F
4
5. The contractor will furnish all information and reports required by Executive Order
11246 of September 24, 1965, and of the rules, regulations, and relevant orders of the
Secretary of Labor, or pursuant thereto, and will permit access to his books, records,
and accounts by the contracting agency and the Secretary of Labor for purposes of
investigation to ascertain compliance with such rules, regulations and orders,
6. In the event of the contractor's noncompliance with the non - discrimination clauses of
this contract or with any of such rules, regulations, or orders, the contract may be
canceled, terminated, or suspended in whole or in part and the contractor may be
declared ineligible for further Government contracts in accordance with procedures
authorized in Executive Order 11246 of September 24, 1965, or by rule, regulation, or
order of the Secretary of Labor, or as otherwise provided by law.
7. The contractor will include the portion of the sentence immediately preceding
paragraph 1 and the provisions of paragraphs 1 through 7 in every subcontract or
purchase order unless exempted by rules, regulations or orders of the Secretary of
Labor issued pursuant to Section 204 of Executive Order 11246 of September 24,
1965, so that such provisions will be binding upon each subcontractor or vendor. The
contractor will take such action with respect to any subcontractor or purchase order as
the contracting agency may direct as a means of enforcing such provisions including
sanctions for noncompliance. Provided, however, that in the event the contract
becomes involved in, or threatened with, litigation with a subcontractor or vendor as a
result of such direction by the contracting agency, the contractor may request the
United States to enter into,such litigation to protect the interests of the United States.
M
Print: r£/Z6 ib as r' c; C;—
Title: r CA 1111A
Date:
Business Address: to <
EQUAL EMPLOYMENT OPPORTUNITY CLAUSE
FOR CONTRACTORS SUBJECT TO EXECUTIVE ORDER 11246
The applicant hereby agrees that it will incorporate or cause to be incorporated into any
contract for construction work, or modification thereof, as defined in the regulations of the
Secretary of Labor at 41 CFR Chapter 60, which is paid in whole or in part with funds
obtained from the Federal Government or borrowed on the credit of the Federal
Government pursuant to a grant, contract, loan insurance, or guarantee, or undertaken
pursuant to any federal program involving such grant,, contract, loan, insurance, or
guarantee, the following equal employment opportunity clauses:
During the performance of this contract, the contractor agrees as follows:
1. The contractor will not discriminate against any employee or applicant for employment
because of race, color, religion, sex or national origin. The contractor will take
affirmative action to ensure that applicants are employed, and that employees are
treated during employment without regard to their race, color, religion, sex or national
origin; such action shall include, but not be limited to the following: Employment,
upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or
termination; rates of pay or other forms of compensation; and selection for training,
including apprenticeship. The contractor agrees to post in conspicuous place,
available to employee and applicants for employment, notices to be provided setting
forth the provision of this nondiscrimination clause.
2. The contractor will, in all solicitations or advertisements for employees placed by or on
behalf of the contractor, state that all qualified applicants will receive considerations for
employment without regard to race, color, religion, sex or national origin.
3. The contractor will send to each labor union or representative of workers with which he
has a collective bargaining agreement to other contract or understanding, a notice to
be provided advising the said labor union or worker's representatives of the
contractor's commitments under section 202 of Executive Order 11246 of September
24, 1965, and shall post copies of the notice in conspicuous places available to
employees and applicants for employment.
4. The contractor will comply with all provisions of Executive Order 11246 of September
24, 1965, and of the rules regulations, and relevant orders of the Secretary of Labor.
Page 1 of 2
23 - EQUAL EMPLOYMENT OPPORTUNITY CLAUSE FOR CONTRACTORS SUBJECT TO EXECUTIVE ORDER 11246
MUami Vade County PHCD
Page 49