Form A-1 - Sworn Statement Under Section 287.133(3)(A), Florida Statutes, On Public Entity Crimes
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1
2FORM A-1
SWORN STATEMENT UNDER 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 OFFICER 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 is____________________________________________________________
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 287.133(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 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 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.
I 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 1, 1989, as a result of a jury verdict, nonjury trial, or entry of a
plea of guilty or nolo contendere.
4.
I understand that an "affiliate" as defined in Paragraph 287.133 (1)(a), Florida Statutes, means:
1. A predecessor or successor of a person convicted of a public entity crime; or
2. 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.
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 applies to bid 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.
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