2-1.1 - Exhibits.pdf

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Attached to
Consultant Services for Locomotive Maintenance Agreement
Solicitation number
RFP 26-007
Issued by
Broward County, Florida

About this file

This exhibits document for RFP No. 26-007 outlines the evaluation criteria, proposal forms, and supporting certifications required by the South Florida Regional Transportation Authority (SFRTA) for Consultant Services related to a Locomotive Maintenance Agreement. SFRTA seeks consultant assistance beginning January 2026 to assess whether entering into a long-term maintenance agreement with Siemens Mobility—specifically a Technical Support and Spares Supply Agreement (TSSSA)—for Charger locomotive maintenance, parts supply, and support is beneficial, and if so, to determine the most advantageous agreement form and assist with negotiations. The contract term is six months from the date of the Notice to Proceed, with a maximum budget not to exceed $100,000. Proposals must include a schedule of hourly billing rates for anticipated consultant personnel categories, and any additional services beyond the scope would require contract amendments.

Evaluation of proposals will be based on two criteria: Technical Score (maximum 75 points) assessing the firm's expertise in TSSSA assessments and negotiations, experience with transportation and public sector agencies, and personnel availability; and Price Proposal (maximum 25 points) calculated on a sliding scale formula where the lowest bidder receives full points. Proposals exceeding $100,000 will be deemed non-responsive and rejected. Required submittals include a Contractor's Qualification Certification detailing firm experience, references, litigation history, and similar projects completed in the past five years; a Drug-Free Workplace Certificate; a Truth-in-Negotiation Certificate; an E-Verify compliance affidavit; and a Human Trafficking Affidavit. All proposals are non-withdrawable for 180 days following the submission deadline, and the selected contractor must comply with Florida's E-Verify system requirements and federal employment eligibility verification standards.

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Exhibit 1

RFP No. 26-007 EX1-1 OF 1

EVALUATION CRITERIA

RFP No. 26-007

CONSULTANT SERVICES FOR LOCOMOTIVE MAINTENANCE AGREEMENT

The criteria below will be used to evaluate each Proposal. There are two (2) criteria, with points assigned to each according to their relative importance to the overall evaluation process for this

RFP.

A. TECHNICAL SCORE (Maximum 75 Points)

The expertise, experience and qualifications of both the Firm and its proposed personnel for the Project in:

• assessing SFRTA’s needs for a TSSSA, and negotiating TSSSA agreements, particularly within the last year;

• in working with transportation agencies, local governments, and other public sector agencies; and

• the availability of the Firm’s proposed personnel to meet the requirements described in the Scope of Services and to begin Work by January, 2026.

B. PRICE PROPOSAL (Maximum 25 Points)

The Proposer offering the lowest total Price Proposal shall receive the maximum 25 points for this criterion. The remaining Proposers shall be rated on a sliding scale using the following formula:

S = ( a ) x 25 b where:

a = dollar amount of the lowest price proposal b = dollar amount of price proposal to be rated S = Price Proposal Score

Exhibit 2

RFP No. 26-007 EX2-1 OF 1

PROPOSAL FORM

RFP No. 26-007

PROPOSER :

PROPOSALS WILL BE DUE PURSUANT TO SECTION 1.4 OF THE INSTRUCTIONS

TO PROPOSERS AND MAY NOT BE WITHDRAWN WITHIN ONE HUNDRED

EIGHTY (180) DAYS AFTER SUCH DATE.

THE PROPOSER CERTIFIES that this proposal is made without prior understanding, agreement or connection with any corporation, firm, or person submitting a proposal for the same contractual services and is in all respects fair and without collusion or fraud. The Proposer agrees to abide by all conditions of the Contract Documents and certifies that it is authorized to submit this proposal and that the proposal is in compliance with all requirements of the Request for Proposal, including but not limited to, certification requirements.

The Proposer further declares that it has examined the Contract Documents and addenda thereto and that it understands the requirements of the Work to be performed and all other requirements of the Request for Proposal.

The Proposer further certifies that neither the bidding firm nor any of its officers are listed on the United States comptroller General’s List of Ineligible Contractors for Federally Financed or Assisted Projects.

Authorized Signature Printed Name

Addenda: Provide signature and date for each Addenda received.

1. 2. 3.

4. 5. 6.

Exhibit 3

RFP No. 26-007 EX3-1 OF 2

PRICE PROPOSAL FORM

REQUEST FOR PROPOSAL (RFP) 26-007

This is an informal procurement and that any proposal in excess of $100k shall be deemed non-responsive and rejected by SFRTA.

Description Not-to-Exceed Price (NTE)

Total Price – assessing whether it is beneficial for SFRTA to enter into a long-term maintenance agreement with Siemens Mobility (Siemens) including possibly a Technical Support and Spares Supply Agreement (TSSSA) for maintenance, parts supply and/or support for Charger locomotives (“Maintenance Agreement”) and if so, what form of the Maintenance Agreement offered by Siemens is most advantageous to SFRTA

$___________________/NTE

Total Price – if SFRTA elects to enter into a Maintenance Agreement, to assist it with negotiations of that agreement.

$___________________/NTE

TOTAL PRICE PROPOSAL AMOUNT $__________________________

* Proposer is to include a schedule of hourly billing rates for anticipated Consultant personnel categories. The schedule of hourly billing rates will be applicable in the event any additional services are required of the Proposer. Additional services would be negotiated as a Contract Amendment.

Exhibit 3

RFP No. 26-007 EX3-2 OF 2

Contractor

Authorized Person (Print or Type) Title

Address

Telephone

Signature

County Of State Of Affix Corporate Seal (If Applicable)

The foregoing instrument was acknowledged before me on this ______ day of _______, 20____

By __________________________________________________________________________

___ An individual acting in their own right;

___ __________________ of ________________________________ Title Corporation/Company a _________________ Corporation, on behalf of the corporation.

State

___ Acknowledging partner/agent on behalf of _______________________________ a partnership. Name of partnership

This person is personally known me or has produced ________________________ as identification and who (did/did not) take an oath.

____________________________________ Place Notary Seal Here Signature of Person Taking Acknowledgment

In lieu of Stamp: ______________________ ______________________________ Type or Print Name Title

Expiration Date

Exhibit 4

RFP No. 26-007 EX4-1 OF 4

CONTRACTOR’S QUALIFICATION CERTIFICATION

Firm Name:_______________________________________________________________

Address:__________________________________________________________________

City,State,Zip:_____________________________________________________________

Telephone: ( ) _____________________ Fax: ( ) __________________

Contact Person:____________________________Title:____________________________

E-Mail Address:_________________________________________

FEID # _____________ DUNS # __________________

1. [RESERVED]

Certified By:________________________________________________________________

2. Specify the principal product or service offered by your firm:

3. Identify the area(s) which the business serves:__ Miami-Dade__ Broward __ Palm Beach __Florida __Other__________________

4. Date business was established:_______________ Occupational License:____________

5. Type of Business:

A. ___Sole Proprietor Name_________________________________________________________________________ Home Address__________________________________________________________________ Home Phone ________________________ Cell Phone_________________________________ Professional license/Certificate of Competency#_______________________________________

B. ___Partnership Are the owners of the business lawful, permanent residents of Florida? ___Yes ___No Provide the name, residential address and telephone number of all owners of the business.

Partners Name Res. Address Phone Number Cell Number

Professional license/Certificate of Competency #:_____________________________________ Name in which license/Certificate of Competency is issued:_____________________________

RFP No. 26-007 EX4-2 OF 4

C. ___Corporation Incorporated in the state of ___________ Date______________

Officer’s Names Title Location

Professional license/Certificate of Competency #: ___________________________________

Name in which license/Certificate is Issued________________________________________

6(a). List each contract completed by you during the last five (5) years, or if less than five (5) contracts have been completed in the last five (5) years, list the last five (5) contracts completed for which liquidated damages or other contractually stipulated sums or damages were assessed against you for failure to complete the work on time or for any other breach of contract by you. For each such contract, provide a brief description of the work performed, the initial contract amount, the dollar amount at completion, date completed, and the name and telephone number of the owner’s representative.

Contract Number

Description of Contract

POC &

Phone

Initial Amount

Closeout Amount

Date Completed

6(b). For the last five (5) years, list each contract under which the owner has called upon your surety to complete the work, has terminated for default, or sued to complete performance or recover damages. If fewer than five (5) contracts have been so affected during the last five (5) years, list the last five (5) contracts to be so affected. For each such contract, provide the same information as required in (a) above, and in addition, provide the name and contract person with telephone number of your surety.

RFP No. 26-007 EX4-3 OF 4

Contract Number

Description of Contract

POC & Phone Initial Amount

Closeout Amount

Date Comp

Surety POC & Phone No.

6(c). List the details of any litigation which your firm has been involved with for the past five

(5) years (Attach pages if necessary).

7. References (Please list prior similar projects)

Year Project Name Company Name

Dollar Amount

Contact Person and E-mail

Estimated amount of current work under contract: $_____________________________

8. List three (3) major contracts similar in scope currently underway or completed within the last five (5) years

Project No. and Title Owner Value Percent Complete

Contact Person and E-mail

RFP No. 26-007 EX4-4 OF 4

I, ___________________________________, ____________________________________, OF

____________________________________, CERTIFY THE INFORMATION PROVIDED ON

THIS QUALIFICATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

Signature Affix Corporate Seal

COUNTY OF _______________________________

STATE OF _______________________________

The foregoing instrument was acknowledged before me on this ______ day of _______, ______ By __________________________________________________________________________

___ An individual acting in their own right;

___ __________________ of ________________________________ Title Corporation/Company a _________________ Corporation, on behalf of the corporation.

State

___ Acknowledging partner/agent on behalf of _______________________________ a partnership. Name of partnership

This person is personally known me or has produced ________________________ as identification and who (did/did not) take an oath.

____________________________________ Place Notary Seal Here Signature of Person Taking Acknowledgment

In lieu of Stamp: ______________________ ______________________________ Type or Print Name Title

Exhibit 5

RFP No. 26-007 EX5-1 OF 2

DRUG FREE WORKPLACE CERTIFICATE

The undersigned vendor hereby certifies that it will provide a drug-free workplace program by:

1. Publishing a statement notifying its employees that the unlawful manufacture, distribution, dispensing, possession, or use of controlled substance is prohibited in the Bidder’s workplace, and specifying the actions that will be taken against employees for violations of such prohibition;

2. Establishing a continuing drug-free awareness program to inform its employees about:

a. The dangers of drug abuse in the workplace;

b. The Bidder’s policy of maintaining a drug-free workplace;

c. Any available drug counseling, rehabilitation, and employee assistance programs;

d. The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;

3. Giving all employees engaged in performance of the contract a copy of the statement required by paragraph 1;

4. Notify all employees, in writing, of the statement required by paragraph 1, that as a condition of employment on a covered contract, the employee shall:

a. Abide by the terms of the statement;

b. Notify the employer in writing of the employee’s conviction under a criminal drug statute for a violation occurring in the workplace no later than five calendar days after such conviction;

5. Notifying South Florida Regional Transportation Authority in writing within ten calendar days after receiving notice under subdivision 4(a) above, from an employee or otherwise receiving actual notice of such conviction. The notice shall include the position title of the employee;

6. Within thirty (30) calendar days after receiving notice under paragraph 4 of a conviction, taking one of the following actions with respect to an employee who is convicted of a drug abuse violation occurring in the workplace:

a. Taking appropriate personnel action against such employee, up to and including termination; or

b. Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a federal, state or local health, law enforcement, or other appropriate agency; and

7. Making a good faith effort to maintain a drug-free workplace program through implementation of paragraphs 1 through 6.

Exhibit 5

RFP No. 26-007 EX5-2 OF 2

Firm: ________________________________________________ (Please print or type)

By: ________________________________________________ Authorized Signature

Name of Authorized Signature Date

Affix Corporate Seal (If Applicable) County Of State Of

The foregoing instrument was acknowledged before me on this ______ day of _______, ______ By __________________________________________________________________________

___ An individual acting in their own right;

___ __________________ of ________________________________ Title Corporation/Company a _________________ Corporation, on behalf of the corporation.

State

___ Acknowledging partner/agent on behalf of _______________________________ a partnership. Name of partnership

This person is personally known me or has produced ________________________ as identification and who (did/did not) take an oath.

____________________________________ Place Notary Seal Here Signature of Person Taking Acknowledgment

In lieu of Stamp: ______________________ ______________________________ Type or Print Name Title

Exhibit 6

RFP No. 26-007 EX6-1 OF 1

TRUTH-IN-NEGOTIATION CERTIFICATE

For the work described as:

I hereby certify that I am the (title) and duly authorized representative of the Firm whose name is and whose address is: .

In connection with the Firm's bid or price proposal for this firm fixed price, negotiated or change order contract which is to be submitted to the South Florida Regional Transportation Authority (SFRTA) for approval, I hereby certify, to the best of my knowledge, information, and belief, that:

(a) The wage rates and other factual unit costs supporting the Firm's compensation, as set forth in the bid or proposal, are accurate, complete and current as of the time of the contracting;

(b) It is my understanding and the understanding of the Firm I here represent that if any of the items of compensation under the above mentioned contract were increased due to the furnishing of inaccurate, incomplete or non-current wage rates or other units of costs, the SFRTA is entitled to an adjustment in all appropriate items of compensation, including profit, to exclude any significant sum by which the price was increased because of the defective data. It is also my understanding and that of the Firm I here represent that the SFRTA’s right of adjustment includes the right to a price adjustment for defects in cost or pricing data submitted by a prospective or actual subcontractor.

(c) It is my understanding and the understanding of the Firm I here represent that if additions are made to the original price of the contract, such additions may be adjusted to exclude any significant sums where it is determined the price has been increased due to inaccurate, incomplete or non-current wage rates and other factual costs.

Date Signature_______________________

Sworn to and subscribed to before me this day of , 20 . Official Seal must be affixed.

Signature of Notary Public ____________________________________

My Commission Expires ____________________________________

(SEAL)

Exhibit 7

RFP No. 26-007 EX7-1 OF 2

SOUTH FLORIDA REGIONAL TRANSPORTATION AUTHORITY (SFRTA)

COMPLIANCE WITH THE U.S. DEPARTMENT OF HOMELAND SECURITY

U.S. CITIZENSHIP AND IMMIGRATION SERVICES

EMPLOYMENT ELIGIBILITY VERIFICATION (E-VERIFY)

THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY

PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS.

This sworn statement is submitted to: South Florida Regional Transportation Authority.

by ___________________________________________________________________________ (print individual’s name and title) for ___________________________________________________________________________ (print name of entity submitting sworn statement) whose business address is: ________________________________________________________ and (if applicable) it’s Federal Employer Identification Number (FEIN) is __________________ (if the entity has no FEIN, include Social Security Number of the individual signing this sworn statement:

I, being duly first sworn state:

That the above name firm, corporation or organization is in compliance with and agree to continue to comply with, and assure that any sub-contractor, or third-party contractor under this project complies with all applicable requirements of the laws listed below including, but not limited to, those provisions pertaining to employment, provisions or programs and services, transportation, communication, access to facilities, renovations, and new construction.

Pursuant to Section 448.095, Florida Statutes, all contractors providing labor, supplies, or services to the SFRTA are required to register with and use the U.S. Department of Homeland Security’s E-Verify system to verify the work authorization status of all employees hired during the term of an agreement with SFTRA to provide labor, supplies, or services and must, upon request, provide evidence of compliance with this provision.

Contractors shall also require all subcontractors performing work under an agreement to provide labor, supplies, or services to SFRTA to use the E-Verify system for any employees they may hire during the term of the agreement. Subcontractors shall provide the contractor with an affidavit

Exhibit 7

RFP No. 26-007 EX7-2 OF 2 stating the subcontractor does not employ, contract with, or subcontract with an unauthorized alien, as stated in Section 448.095, Florida Statutes. Contractor shall provide a copy of such affidavit to the SFRTA upon receipt and shall maintain a copy for the duration of the agreement.

The E-Verify program is found in Title IV, Subtitle A, of the Illegal Immigration Reform and Immigration Responsibility Act of 1996 (IIRIRA), Pub. L. 104-208, 110 Stat. 3009, as amended (8 U.S.C. § 1324a note). Authority for use of the E-Verify program by Federal contractors and subcontractors is covered by the terms of Subpart 22.18, “Employment Eligibility Verification”, of the Federal Acquisition Regulation (FAR) and in Executive Order 12989, as amended.

(Signature)

Sworn to and subscribe before me this ______ day of __________________________, 20_____

Personally known _______________________________________________________________ or produced identification: Notary Public, State of ___________

_______________________________ My Commission Expires _________ (Type of Identification)

(Printed, typed or stamped commissioned name of Notary Public)

Exhibit 8

RFP No. 26-007 EX8-1 OF 1

SOUTH FLORIDA REGIONAL TRANSPORTATION AUTHORITY

NO SUBMITTAL NOTICE

Dear Vendor/Firm:

The Procurement Department of the South Florida Regional Transportation Authority has solicited your participation for RFP NO. 26-007, entitled CONSULTANT SERVICES FOR LOCOMOTIVE MAINTENANCE AGREEMENT. Please complete this form only if you do not intend to submit a proposal on this project. SFRTA is interested in improving its competitive bid process and your comments are important to this endeavor. Thank you for your assistance.

I do not intend to bid on this project because:

( ) Do not have the necessary equipment, labor, and capital required.

( ) Do not have the experience necessary to perform the work.

( ) Heavy workload makes bidding impossible at this time.

( ) Unable to get bonding and/or special insurance.

(Be specific) _______________________________________________________

( ) Insufficient time to complete the work.

( ) General Conditions/Specifications contains requirements which I do not understand. (Explain) _______________________________________________

( ) General Conditions/Specifications contains requirements with which I disagree.

(Explain) _________________________________________________________

Comments: _____________________________________________________________

( ) Retain my name on SFRTA’s vendor list ( ) Remove my name from SFRTA’s vendor list

(Company Name) (Signature)

Please email this form to bids@sfrta.fl.gov

Exhibit 9

RFP No. 26-007 EX9-1 OF 5

AGREEMENT NO. 26-007

BETWEEN

AND

FOR

RFP No. 26-007 EX9-2 OF 5

AGREEMENT NO. 26-007

BETWEEN

FOR

This is an Agreement, by and between SOUTH FLORIDA REGIONAL TRANSPORTATION AUTHORITY, hereinafter referred to as “SFRTA”, ____________________________, a ______________, authorized to and doing business in the State of Florida, hereinafter referred to as “CONTRACTOR” or “CONSULTANT.”

RECITALS

A Request for Proposal was advertised by SFRTA as RFP No. 26-007, for TECHNICAL SUPPORT AND SPARES SUPPLY AGREEMEN, and CONTRACTOR was determined to be the most qualified responsive and responsible respondent;

NOW, THEREFORE, IN CONSIDERATION of the promises, mutual covenants and obligations herein contained, and subject to the terms and conditions hereinafter stated, the parties hereto agree to the Agreement as follows:

ARTICLE I

SERVICES

CONTRACTOR covenants and agrees to perform all services and other obligations of

CONTRACTOR set forth in the Contract Documents, as defined in the RFP. The Contract Documents are hereby incorporated and made a part of this Agreement by this reference.

RFP No. 26-007 EX9-3 OF 5

ARTICLE II

TERM

The term of the Agreement shall be for six (6) months commencing on the date of SFRTA’s issuance of a Notice to Proceed.

ARTICLE III

COMPENSATION

1. SFRTA agrees to pay the CONTRACTOR compensation as specified in the CONTRACT

DOCUMENTS the total not-to-exceed amount of _____________________

2. SFRTA, during any fiscal year, shall not expend money, incur any liability or enter into any contract which, by its terms, involves the expenditure of money in excess of the amounts budgeted as available for expenditure during such fiscal year. Any contract, verbal or written, made in violation of this subsection is null and void and no money may be paid on such contract.

ARTICLE IV

NOTICES

Whenever either party desires to give notice to the other, it must be given by written notice, sent by certified U.S. mail, with return receipt requested, facsimile transmission, express delivery service or hand delivery, addressed to the party for whom it is intended, at the place last specified, and the place for giving of notice shall remain such until it shall have been changed by written notice in compliance with the provisions of this paragraph. For the present, the parties designate the following as the respective places for giving of notice:

CONTRACTOR:

Attn: _____________________

RFP No. 26-007 EX9-4 OF 5

SFRTA:

South Florida Regional Transportation Authority 801 N.W. 33rd Street Pompano Beach, FL 33064 Attn: Project Manager

WITH COPY TO:

South Florida Regional Transportation Authority Teresa Moore, General Counsel 801 N.W. 33rd Street Pompano Beach, FL 33064

RFP No. 26-007 EX9-5 OF 5

IN WITNESS WHEREOF, the parties have made and executed this Agreement on the respective date under each signature:

SOUTH FLORIDA REGIONAL

TRANSPORTATION AUTHORITY, a body politic and corporate and an agency of the State of Florida created pursuant to Chapter 343, Florida Statutes.

ATTEST:

By: ________________________________ By: ______________________________________ Anthony Cariveau DAVID W. DECH SFRTA Chief Contracting Officer SFRTA Executive Director

Date:

Approved by General Counsel as to legal form and sufficiency:

TERESA J. MOORE, Esq.

SFRTA General Counsel

ATTEST: (CONTRACTOR NAME)

WITNESS PRESIDENT OR VICE-PRESIDENT

_______ DAY OF _________________, 2026

Exhibit 10

RFP No. 26-007 EX10 -1 OF 3

Contractor Performance Evaluation

SFRTA will periodically evaluate the Contractor’s performance utilizing the Contractor Performance Evaluation Form in Exhibit 10. This evaluation will be done at an interval no less than once per year during the Contract Term. For contracts with a term less than one year, the evaluation may be performed intermittently as determined by SFRTA. The SFRTA assigned evaluator shall complete the Contractor Performance Evaluation Form and provide a copy to the Contractor for review and response. Written Contractor responses will be incorporated into the evaluations. In any instances where the performance is below satisfactory, the Contractor will have thirty (30) days to provide a written response to SFRTA.

RFP No. 26-007 EX10 -2 OF 3

CONTRACTOR PERFORMANCE EVALUATION FORM

CONTRACTOR:______________________________________________________

ADDRESS:_________________________________________________________

PROJECT NAME:____________________________________________________

CONTRACT NO.____________________ AWARD DATE:____________________

EVALUATION NO._____ DATE:__________ PERIOD COVERED:______TO______

EVALUATED BY:____________________________________________________

(Signature & Title)

CONTRACTUAL ACTUAL *

PRICE:

COMPLETION DATE:

TIME TO COMPLETE

Ratings:

E = Excellent G = Good S = Satisfactory U = Unsatisfactory N/A = Not Applicable

* = For Final Evaluation Only. Actual includes contractual plus all Amendments and Change orders.

RFP No. 26-007 EX10 -3 OF 3

EVALUATION OF CONTRACTOR'S PERFORMANCE

EVALUATED ITEM EVALUATION NO.

1 2 3 4

Quality of Contractor's Work

Adherence to Contract Specs/Scope of Services

Quality of Subcontractor's Work

Quality of Project Manager/Supervisory Personnel

Protection of SFRTA Property

Minimal interference with SFRTA Operations

Timely submission of Reports, Project Schedules and Deliverables

Adherence to Project Schedule

Compliance with Safety Standards

Communication with SFRTA Project Manager

Attendance at Project Meetings

Cooperation with Other Contractors

Timely Notification of Possible Delays

* * * OVERALL EVALUATION * * *

COMMENTS: _______________________________________________________

*NOTE: PLEASE ATTACH BACKUP DOCUMENTATION FOR ALL EVALUATIONS

RATED BELOW SATISFACTORY OR AS REQUESTED BY PROCUREMENT.

Exhibit 11

RFP No. 26-007 EX11 -1 OF 1

HUMAN TRAFFICKING AFFIDAVIT

Florida Statutes §787.06(13) requires all nongovernmental entities executing, renewing, or extending a contract with a governmental entity to provide an affidavit signed by an officer or representative of the nongovernmental entity under penalty of perjury that the nongovernmental entity does not use coercion for labor or services as defined in that statute. The South Florida Regional Transportation Authority “SFRTA”) is a governmental entity for the purposes of this statute.

As the officer or representative of _________________________________ (the “Company), I certify that the Company does not, for labor or services,

• Use or threaten to use physical force against any person;

• Restrain, isolate, or confine or threaten to restrain, isolate, or confine any person without lawful authority and against his or her will;

• Use lending or other credit methods to establish a debt by any person when labor or services are pledged as a security for the debt, if the value of the labor or services as reasonably assessed is not applied towards the liquidation of the debt, the length and nature of the labor or services are not respectively limited and defined;

• Destroy, conceal, remove, confiscate, withhold, or possess any actual or purported passport, visa, or other immigration document, or any other actual or purported government identification, of any person;

• Cause or threaten to cause financial harm to any person;

• Entice or lure any person by fraud or deceit;

• Provide controlled substances as outlined in Schedule I or Schedule II of Florida Statutes

§893.03 to any person for the purpose of exploitation of that person.

Under penalty of perjury, I hereby declare and affirm that the above stated facts are true and correct.

_______________________________ “Company”

By: ____________________________________

Print Name: _____________________________

Print Title: _______________________________

STATE OF _______________

COUNTY OF _____________

The foregoing instrument was sworn to and subscribed before me by means of

☐ physical presence or online notarization, this _______ day of _____________________, 2025, by __________________________________, as ________________________ of [insert company name], a __________________________________, who is personally known to me, or produced _______________________________ as identification.

Notary Public Signature [AFFIX NOTARY SEAL] Print Notary Name:__________________ My commission expires: ___________

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