SWORN STATEMENT COUNTRYSIDE BOULEVARD WIDENING
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sw<IRN STATEMENT UNDER SECTION 287.113(3)(a),
FLIRIDASTATUTES. ON PUllUC ENTITY ClIMES
THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED TO ADMINISTER OATHS.
1. This sworn statement is submitted with Bid, Proposal or Contract No.
fur Countryside Boulevard Widening Project
2. This sworn statement is submitted by Tampa Bay Engineering, Inc.
[name of entity submitting swom statement]
whose business address is
2240 Belleair Road, Suite 200, Clearwater, FL 34624
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
59-2367433
statement:
.)
entity named above is
Patrick L. Beyer
[please print name of individual signing]
,
President
and my relationship to the
3.
My name is
4. 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 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 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.
5. I understand that "convicted" or "conviction" as detiTled 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. .'
6..I.~hderstand 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. All entity under the control of any natural person who is active in the management of the
elltity 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.
7. 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.
8. Based on information and belief, the statement which I have marked below is true in relation to the
entity submitting this sworn statement. [Please indicate which statement applies.]
~ Neither the entity, submitting this sworn statement, nor any officers, directors, executives,
partners, shareholders, elployees, members, or agents who are active 11 management of the entity,
nor any affiliate of the-~ntity have been charged with and convictld of a public entity crime
subsequent to July 1, 1989.
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_ The entity submitting this sworn statement, or one or more of the 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, AND [Please indicate which additional statement applies.]
_ There has been a proceeding concerning the conviction before a hearing officer of
the State of Florida, Division of Administrative Hearings. The final order entered by the
hearing officer did not place the person or affiliate on the convicted vendor list. [Please
attach a copy of the final order.]
_ The person or affiliate was placed on the convicted vendor list. There has been a
subsequent proceeding before a hearing officer of the State of Florida, Division of
Administrative Hearings. The final order entered by the hearing officer detennined that it
was in the public interest to remove the person or affiliate from the convicted vendor list.
[Please attach a copy of the final order.]
'_ The person or affiliate has not been placed on the convicted vendor list. [Please
de!cribeanyfittiOff takeni>ym" pendin~",iththeDepal"tment of, General Services.]
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Date: October 19, 1990
STATE OF
COUNTY OF
FLORIDA
PINELLAS
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
Pat r i c k L. Be ye r who, after first being sworn by me, affixed his/her signature
[name of individual signing]
My commission expires:
19th day of October . 19 90 .
~- ~ ()LL~
OOTARY PUBLIC
in the space provided above on this
Notary Public, 8tate of Florida
u --_My Commission ElI:plrl\sMar. 29,.1_994
Bonded thru PICHARD Ins. Agency
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October 19, 1990
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Mr. Cecil M, Henderson, Jr., P.E.
Assistant Director of Public Work/Engineering Group
City of Clearwater
P. O. Box 4748
Clearwater, FL 34618-4748
Re: Countryside Boulevard Widening Project
Dear Mr. Henderson:
Enclosed is our executed State of Florida Public Entity Crimes forms as
requested in your letter of October 12, 1990.
Very truly,
TAMPA BAY ENGINEERING, INC.
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Bonnie J. Beetle:
Office Manager---.
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Enclosure
FAX (813) 539-1294
Tampa Une (813) 854-2104
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C I T Y
Mr. Brol -
The attached sent to your
previous address (in error).
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Sorry, for the mix-up!
4748
October 12, 1990
Sincerely, /7
O.h,-- {p~
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Staff Asst. I
,748
---
Mr. Robert Brown, P.E.
Tampa Bay Engineering, Inc.
1452 US 19 South, Suite 510
Clearwater, Florida 33546
Re: Countryside Boulevard Widening Project, Engineering
Services Agreement, State of Florida Public Entity Crimes
Form
Dear Mr. Brown:
Attached is a State of Florida Public Entity Crimes form
which is required on all government contracts. This form
must be filled out by your firm and returned to this office
prior to the execution of the above proposed Engineering
Services Agreement.
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Cecil M. Henderson Jr., P.E.
Assistant Director of Public Works/Engineering Group
CMH/TCJ/jlp
Attachment
cc: Engineering Division Project File
RECEIVED
Tampa Bay Engineerlng, Ino.
Clearwater, Fiori~a
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OCT 1 7 1990
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