05. Attachment 6.docx

STATE OF FLORIDA

DEPARTMENT OF FINANCIAL SERVICES

APPENDIX C

Mandatory Criteria Certification Form

By submitting this form, and the PUR 7801 which appears on the next pages, the Respondent acknowledges that the Department will rely on the representations made on this form and the PUR 7801 in making its decision of award. If the Department discovers that any of the information on this form is false prior to the award of the Contract, the Department reserves the right to deem the Respondent non-responsive and cease any consideration of its Response. If the Department discovers that any information on this form is false after the award to the Respondent is made, the Department reserves the right to terminate the Contract and hold the Respondent liable for costs associated with re-procurement.

A Respondent’s failure to provide the below certification for each Certification Question and/or the PUR 7801 below will result in the Respondent being deemed non-responsive. Annual resubmissions of the following attestation forms will not require a written amendment to the Contract.

As the person authorized to sign this form, I certify that the Certification Answers provided below are accurate as to the Respondent.

Respondent Name: _____________________________________________________________________

Authorized Representative: __________________________ __________________________ ______ Printed Name Signature Date

Attachment 7, Mandatory Criteria Certification Form v2024.11.13 Page 1 of 10 Form PUR 7801 (07/2024) Rule 60A-1.002, F.A.C.

Vendor Certification Form

I hereby certify the following on behalf of the vendor identified below:

The vendor is hereby informed of the provisions of sections 287.133(2)(a), 287.134(2)(a), and 287.137(2)(a), F.S., that identify the impacts to the vendor's ability or its affiliates’ ability to respond to the competitive solicitations of a public entity; to be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with a public entity; or to transact business with a public entity if it, or its affiliates, are placed on the Convicted Vendor, Discriminatory Vendor, or Antitrust Violator Vendor Lists of the Department of Management Services. The vendor is hereby further informed of the provisions of section 287.1351, F.S., that identify the impacts to the vendor’s ability to enter into or renew a contract with an agency, as defined in section 287.012, F.S., if it is placed on the Suspended Vendor List of the Department of Management Services.

By signing below, I certify that I am authorized to complete and submit this Vendor Certification Form on behalf of the vendor.

Vendor Information Signatory

Name Signature Date

FEIN Typed or Printed Name

Title

Form PUR 7801 (07/2024) Rule 60A-1.002, F.A.C.

FOREIGN COUNTRY OF CONCERN ATTESTATION

(PUR 1355)

This form must be completed by an officer or representative of an entity submitting a bid, proposal, or reply to, or entering into, renewing, or extending, a contract with a Governmental Entity which would grant the entity access to an individual’s Personal Identifying Information. Capitalized terms used herein have the definitions ascribed in Rule 60A-1.020, F.A.C.

Name of entity is not owned by the government of a Foreign Country of Concern, is not organized under the laws of nor has its Principal Place of Business in a Foreign Country of Concern, and the government of a Foreign Country of Concern does not have a Controlling Interest in the entity.

Under penalties of perjury, I declare that I have read the foregoing statement and that the facts stated in it are true.

Printed Name:

Title:

Signature: Date:

Form PUR 1355 (07/2024) Rule 60A-1.020, F.A.C.

COMMON CARRIER OR CONTRACTED CARRIER ATTESTATION FORM

(PUR 1808)

This form must be completed by a Common Carrier or contracted carrier and submitted to the Governmental Entity with which a Contract being is executed, amended, or renewed. Capitalized terms used herein have the definitions ascribed in section 908.111, F.S.

[Name of Common Carrier or contracted carrier] is not willfully providing and will not willfully provide any service during the Contract term in furtherance of transporting a person into this state knowing that the person is an Unauthorized Alien, except to facilitate the detention, removal, or departure of the person from this state or the United States.

Under penalties of perjury, I declare that I have read the foregoing statement and that the facts stated in it are true.

Printed Name:

Title:

Signature: Date:

Form PUR 1808 (07/2024)

Rule 60A-1.020, F.A.C.

PUR 2024

Part A: Use of Coercion for Labor and Services

Pursuant to section 787.06(13), Florida Statutes, this portion of the form must be completed by an officer or representative of the nongovernmental entity executing, renewing, or extending a contract with a governmental entity.

Name of entity does not use coercion for labor or services as defined in section 787.06, Florida Statutes.

Under penalties of perjury, I declare that I have read the foregoing statement and that the facts stated in it are true.

Entity Name:

Representative/Officer’s Printed Name:

Representative/Officer’s Title:

Signature: Date:

Part B: Provision of Commodities Produced by Forced Labor

Pursuant to section 287.1346(4)(b), Florida Statutes, this portion of the form must be completed by a member of the company’s senior management, as defined in section 287.1346, F.S., when the company submits a response to a solicitation for the provision of commodities and before the company enters into or renews a contract for the provision of commodities.

I certify that to the best of my knowledge, the commodities Name of entity is offering to the Department have not been produced, in whole or in part, by forced labor.

Entity Name:

Senior Management’s Printed Name:

Senior Management member’s Title:

Signature: Date:

787.06(13) F.S.

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