3-Attachment E-Foreign Country of Concern.pdf

This is a Foreign Country of Concern Attestation form (PUR 1355) required by Halifax Health in Florida for bidders seeking to access personal identifying information through a contract award. The attestation requires that the bidding entity certify under penalties of perjury that it is not owned by, organized under the laws of, nor has its principal place of business in a Foreign Country of Concern, and that no such foreign government maintains a controlling interest in the entity. The form must be completed and signed by an officer or representative of any entity submitting a bid, proposal, or reply, or entering into, renewing, or extending a contract that would grant access to personal identifying information. The attestation applies to the South Machine Room Booster Pump project, which involves removal and replacement of existing booster pumps in the South Machine Room.

This attestation form contains no pricing information, set-asides, incumbent details, or other contract financial terms, as it functions solely as a compliance certification document. Bidders must provide their entity name, printed name of the signatory, title, signature, and date of completion. The form references Rule 60A-1.020, F.A.C., which establishes the definitions and requirements for Foreign Countries of Concern designations under Florida law.