3-Attachment E-Foreign Country of Concern.pdf

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Attached to
CHILLER REPLACEMENT FOR HHPO
Solicitation number
PROJ-25-131
Issued by
Volusia County, Florida

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This document is an Attachment E Foreign Country of Concern Attestation form (PUR 1355) for a governmental entity contract. The form is designed to be completed by an officer or representative of an entity submitting a bid, proposal, or entering into a contract that would provide access to an individual's Personal Identifying Information. The attestation requires the entity to confirm that it is not owned by, not organizationally affiliated with, and does not have a controlling interest from a Foreign Country of Concern, as defined in Rule 60A-1.020, F.A.C.

The form includes signature fields for a printed name, title, signature, and date, with the declarant affirming under penalties of perjury that the statements made are true. The document is a standardized form dated October 2023 (10/23) and is part of a regulatory compliance process to ensure transparency and security in governmental contracts, particularly concerning potential foreign ownership or control that might pose risks to sensitive information.

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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 .