5-AFFIDAVIT OF COMPLIANCE - Denying Doing Business with a Foreign Country of Concern 09.docx
DOCX document 17 KB Posted
- Attached to
- Disposition Services of Unclaimed Bodies
- Solicitation number
- ITB-26-00011
- Issued by
- Hillsborough County, Florida
About this file
This document is an Affidavit of Compliance for Hillsborough County, Florida, specifically addressing requirements related to doing business with foreign countries of concern, as mandated by Florida Statutes 287.138. The affidavit is a mandatory submission for bidders/offerors, effective January 1, 2024, and is required for any contract that would provide access to an individual's personal identifying information. The form requires companies to affirm they are not owned by, controlled by, or principally located in countries designated as "Foreign Countries of Concern," which include China, Russia, Iran, North Korea, Cuba, Venezuela, and Syria.
The related state and local contract opportunity is for Disposition Services of Unclaimed Bodies by the Hillsborough County Medical Examiner Department. The project seeks a qualified contractor to provide services for handling unclaimed bodies over a two-year period, with an estimated project budget of $436,450.00. The affidavit serves as a critical compliance document for potential contractors, ensuring that any entity bidding on this or other county contracts meets specific geopolitical and operational standards designed to protect county interests and sensitive information.
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| 4-Direct Deposit Authorization Form 5.15.2025.pdf.pdf | ||
| 6-ITB-26-00011 Disposition Services of Unclaimed Bodies.pdf | ||
| 3-Substitute W9 Form.pdf.pdf | ||
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Text version
AFFIDAVIT OF COMPLIANCE
DENYING BIDDER’S/OFFEROR’S INVOLVEMENT WITH A FOREIGN COUNTRY OF CONCERN
(Pursuant to Florida Statutes 287.138)
*** THIS AFFIDAVIT MUST BE SUBMITTED WITH BIDDER’S BID/OFFER
(Per Florida Statutes, Section 287.138(4)(a), beginning January 1, 2024, Hillsborough County cannot accept a bid on, a proposal for, or reply to, or enter into a contract with a company/entity which would grant such company/entity access to an individual’s personal identifying information unless the company/entity provides the County with an Affidavit denying the company’s/entity’s involvement with a Foreign Country of Concern.)
______________________________________, being duly sworn deposes and states as follows under penalties of perjury:
(Name of person signing Affidavit)
1. My name is __________________________________________________ (Full Name)
2. I am the ____________________________ of ______________________________________________________ (Job Title – Officer/Authorized Representative) (Company Name)
3. The Company was formed in __________________________________________and is a ____________________ (Country and State) (Type of Entity (e.g., Inc., LLC, etc.)
4. I affirm that I am duly authorized and empowered and have sufficient knowledge to execute and deliver this Affidavit on behalf of the Company stated above.
5. I affirm that I have duly read and understand Florida Statutes Section 287.138 in its entirety and affirm as follows:
** For the purposes of this Affidavit a “Foreign Country of Concern” shall mean the People’s Republic of China, the Russian Federation, the Islamic Republic of Iran, the Democratic People’s Republic of Korea, the Republic of Cuba, the Venezuelan regime of Nicolas Maduro, or the Syrian Arab Republic, including any agency of or any other entity of significant control of such foreign country.
(a) The Company is not owned by the government of a Foreign Country of Concern;
(b) The government of a Foreign Country of Concern has no controlling interest in the Company; and
(c) The Company is not organized under the laws of or does not have its principal place of business in a Foreign Country of Concern.
Under penalties of perjury, I declare that I have read this Affidavit and that the facts stated herein are true:
| __________________________________________ | ||||
| (Signature of Affiant) | ||||
| STATE OF | ) | |||
| COUNTY OF | ) | |||
| The foregoing instrument was acknowledged before me by means of physical presence | ||||
| or online notarization this _____ day of | , 20 | , by_________________________________________. |
(Name of Affiant)
(Signature of Notary Public)
(Print, Type, or Stamp Name of Notary Public) Personally Known OR Produced Identification Type of Identification Produced: ___________________________
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