3-Attachment E-Foreign Country of Concern.pdf

This is a Foreign Country of Concern Attestation form (PUR 1355) required by Halifax Health, a Florida-based governmental entity, for contractors bidding on the SEVCC CU3&CU6 Replacements project. The form must be completed by an authorized officer or representative of any entity submitting a bid, proposal, or reply to, or entering into, renewing, or extending a contract that would grant access to an individual's Personal Identifying Information. The attestation requires the bidding entity to declare under penalties of perjury that it is not owned by the government of a Foreign Country of Concern, is not organized under the laws of a Foreign Country of Concern, does not have its Principal Place of Business in a Foreign Country of Concern, and that the government of a Foreign Country of Concern does not have a Controlling Interest in the entity.

The form requires completion of basic identifying information including the printed name, title, signature, and date of the authorized representative. This attestation is governed by Rule 60A-1.020, F.A.C., and applies to all contractors seeking to provide services or products to Halifax Health in connection with the replacement of two air-cooled condensing units at Southeast Volusia Care Center, which includes demolition and disposal of existing units as part of a turnkey, all-inclusive proposal.