3-Attachment E-Foreign Country of Concern.pdf

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Attached to
HBS RTU REPLACEMENTS
Solicitation number
PROJ-26-073
Issued by
Volusia County, Florida

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This is a Foreign Country of Concern Attestation form (PUR 1355) required by the State of Florida for Halifax Health's request for bid proposals to replace four rooftop units (RTUs: Unit 11, 12, 13, and 14) at Halifax Health Behavioral Services. The attestation must be completed and signed by an officer or representative of any entity submitting a bid, proposal, or reply to, or entering into, renewing, or extending a contract with the governmental entity that would grant access to an individual's Personal Identifying Information.

The attesting entity must certify 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 the entity name, printed name of the signatory, title, signature, and date. Terms referenced in the attestation are defined in Rule 60A-1.020, F.A.C.

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Attachment E

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: __________

PUR 1355 (10/23) Rule 60A-1.020, F.A.C.

PUR 1355 1023:
Rule 60A1020 FAC:
Text1:
Text3:
Text4:

File details come from the government source that posted it. Updated .