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G-4PUBLIC ENTITY CRIMES AND CONFLICTS OF INTEREST Pursuant to the provisions of Paragraph (2) (a) of Section 287.133, Florida State Statutes — "A person or affiliate who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a Proposal or bid on a Contract to provide any goods or services to a public entity, may not submit a Bid or proposal for a Contract with a public entity for the construction of repair of a public building or public work, may not submit bids or proposals on leases or real property to a public entity, may not be awarded to perform Work as a CONTRACTOR, Sub - contractor, supplier, Sub - consultant, or Consultant under a Contract with any public entity, and may not transact business with any public entity in excess of the threshold amount Category Two of Section 287.017, Florida Statutes, for thirty six (36) months from the date of being placed on the convicted vendor list". 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. 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 OFFICIAL AUTHORIZED TO ADMINISTER OATHS. for This sworn statement is submitted to [print name A-0 L, O [print individual's name and title] of the public entity] [pBrint name of entity submitting sworn st tement] rs }� business address and (if applicable) its Federal Employer Identification Number (FEIN) is U6 9 99 (If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement: .) 2. 1 understand that a "public entity crime" as defined in Paragraph 287.133 (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 of any other state or of the United States, including, but not limited to , any bid, proposal or 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. 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 any federal or state trial court of record relating to charges brought by indictment or information after July I, nolo contendere. 1989, as a result of a jury verdict, non -jury trial, or entry of a plea of guilty or 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 (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, Thomas P. Pepe, 2014 Page 27 of 73 4/28/2014 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 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. 5. I understand that a "person" as defined in Paragraph 287.133 (1) (e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or proposal or applies to bid or proposal on contracts for the 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 in management of an entity. 6. Base on information and belief, the statement which I have marked below is true in relation to the entity ubmitting this sworn statement. [Indicate which statement applies.] Neither the entity submitting this sworn statement, nor any 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 to July I, 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 I, 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 of July I, 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 INDENTIFIED IN PARAGRAPH I (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONL THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. Sworn to and subscribed before me this day of Personally known, OR Produced identification (Type of identification) Form PUR 7068 (Rev.06 111(92) OFFICER FOR THE PUBLIC ENTITY f, AND THAT THIS FORM IS VALID ALSO UNDERSTAND THAT I AM CONTRACT IN EXCESS OF THE FOR CATEGORY TWO OF ANY Notary Public -State of 8� My commission expires (Printed, typed or stamped commi Toned name of notary public) © Thomas F. Pepe, 2014 E:::: tate ofOFternida ai2ai2o14 Chag Y on EE112030 Page 28 of 73 DRUG FREE WORKPLACE Whenever two or more Bids or Proposals which are equal with respect to price, quality and service are received by the State or by any political subdivisions for the procurement of commodities 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: I) Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that shall be taken against employees for violations of such prohibition. 2) Inform employees about the dangers of drug abuse in the workplace, the business' policy of maintaining a drug -free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. 3) Give each employee engaged in providing the commodities or contractual services that are under Bid a copy of the statement specified in Subsection (I). 4) In the statement specified in Subsection (1), notify the employees, that, as a condition of working of the commodities or contractual services that are under Bid, he employee shall abide by the terms of the statement and shall notify the employee of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) business days after such conviction. 5) Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program, if such is available in the employee's community, by any employee who is so convicted. 6) Make a good faith effort to continue to maintain a drug -free workplace through implementation of this section. As the person authorized to sign the statement I certi that this firm complies fully with the above requirements. RESPONDENT'S Signature. Print Name: 0-AV 0 Aj _ i D sp Date: OR 6 :? © Thomas F. Pepe, 2014 Page 29 of 73 4/28/2014 TO THE CITY OF SOUTH MIAMI We, a j Y a I/, f�i 6 A AAL °, (Name of CONTRACTOR), hereby acknowledge and agree that as CONTRACTORs for the project as specked have the sole responsibility for compliance with all the requirements of the Federal Occupational Safety and Health Act of 1970, and all State and local safety and health regulations, and agree to indemnify and hold harmless the City of South Miami and against any and all liability, claims, damages, losses and expenses they may incur due to the failure of (Sub - Contractor's names): J Th, m E. Pepe, 2014 Page 30 of 73 a/zsizoia LIST OF PROPOSED SUBCONTRACTORS AND PRINCIPAL SUPPLIERS BIDDER shall list all Proposed Subcontractors to be used on this proj rsrrar Page 31 of 73 RELATED PARTY TRANSACTION VERIFICATION FORM , individually and on behalf of A Y ®fi / ( "Firm')have Name of Representative Company/Vendor /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 I, 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[See Note #1 below], and (3) neither I nor the Firm, nor anyone who has a financial interest greater than 5% in the Firm, nor any member of those persons' immediate family (i.e., spouse, parents, children, brothers and sisters) has transacted or entered into any contmct(s) with the City or has a financial interest, direct or indirect, in any business being transacted with the city, or with any person or agency acting for the city, other than as follows: (K necessary use a separate sheet to supply additional information that will not fit on this line but make reference on the line above to the separate sheet, i.e., "see attached additional information" and make reference to this document and this paragraph on the additional sheet which additional sheet must be signed under oath). [See Note # I below]; and (4) no elected and /or appointed official or employee of the City of South Miami, or any of their immediate family members (i.e., spouse, parents, children, brothers and sisters) has a financial interest, directly or indirectly, in the contract between you and /or your Firm and the City other than the following individuals whose interest is set forth following their use a separate names: (if necessary use a separate sheet to supply additional information that will not fit on this line but make reference on the line above to the separate sheet, i.e., "see attached additional information" and make reference to this document and this paragraph on the additional sheet which additional sheet must be signed under oath). The names of all City employees and that of all elected and /or appointed city officials or board members, who own, directly or indirectly, an interest of five percent (5 %) or more of the total assets of capital stock in the firm are as follows: (d necessary use a separate sheet to supply additional information that will not fit on this line but make reference on the line above to the separate sheet, i.e., "see attached additional information" and make reference to this document and this paragraph on the additional sheet which additional sheet must be signed under oath). [See Note #I below] - (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 privilege, benefit, or exemption for ourselves, or others. We agree that we may not disclose or use information, not available to members of the general public, for our personal gain or benefit or for the personal gain or benefit of any other person or business entity, outside of the normal gain or benefit anticipated through the performance of the contract 0 nccmn F. Pepe, 2014 Page 32 of 73 4/28/2014 (6) 1 and the Firm hereby acknowledge that we have not contracted or transacted any business with the City or any person or agency acting for the City, and that we have not appeared in representation of any third party before any board, commission or agency of the City within the past two years other than as follows: (if necessary use a separate sheet to supply additional information that will not fit on this line but make reference on the line above to the separate sheet, i.e., "see attached additional information" and make reference to this document and this paragraph on the additional sheet which additional sheet must be signed under oath). (7) Neither I nor any employees, officers, or directors of the Firm, nor any of their immediate family (i.e., as a spouse, son, daughter, parent, brother or sister) is related by blood or marriage to: (i) any member of the City Commission; (ii) any city employee; or (iii) any member of any board or agency of the City other than as follows: ^� (if necessary use a separate sheet to supply additional information that will not fit on this line but make reference on the line above to the separate sheet, i.e., "see attached additional information" and make reference to this document and this paragraph on the additional sheet which additional sheet must be signed under oath). [See Note #1 below]; and. (8) No Other Firm, nor any officers or directors of that Other Firm or anyone who has a financial interest greater than 5% in that Other Firm, nor any member of those persons' immediate family (i.e., spouse, parents, children, brothers and sisters) nor any of my immediate family members (hereinafter referred to as "Related Parties') has responded to a solicitation by the City in which I or the Firm that I represent or anyone who has a financial interest greater than 5% in the Firm, or any member of those persons' immediate family (i.e. spouse, parents, children, brothers and sisters) have also responded, other than the following (if necessary use a separate sheet to supply additional information that will not fit on this line but make reference on the line above to the separate sheet, i.e., "see attached additional information" and make reference to this document and this paragraph on the additional sheet which additional sheet must be signed under oath). [while the ethics code still applies, if the person executing this form is doing so on behalf of a firm whose stock is publicly traded, the statement in this section (8) shall be based solely on the signatory's personal knowledge and he/she is not required to make an independent investigation into the Other Firm, or the Firm he /she represents, as to their officers, directors or anyone having a financial interest in those Firms or any of their any member of those persons' immediate family.] (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. Specifically, after the opening of any responses to a solicitation, I and the Firm have an obligation to supplement this Verification Form with the name of all Related Parties who have also responded to the same solicitation and to disclose the relationship of those parties to me and the Firm. (10) A violation of the City's Ethics Code, the giving of any false information or the failure to supplement this Verification Form, may subject me or the Firm to immediate termination of any agreement with the City, and the imposition of the maximum fine and /or any penalties allowed by law. Additionally, violations may be considered by and subject to action by the Miami -Dade County Commission on Ethics. Under penalty of perjury, I declare that I have made a diligent effort to investigate the matters to which I am attesting hereinabove and that the statements made herenabove are true and co ject to the est of my knowledge, information and belief. Signature. Print Name & Title: Date: ® 0 O Thomas F. Pepe, 2014 Page 33 of 73 4/28/2014