5-AFFIDAVIT OF COMPLIANCE - Denying Doing Business with a Foreign Country of Concern 09.docx
DOCX document 17 KB Posted
- Attached to
- Cold Weather Shelter Partnerships
- Solicitation number
- RFQ-26-00101
- Issued by
- Hillsborough County, Florida
About this file
This is an Affidavit of Compliance form required by Hillsborough County, Florida, for vendors seeking to do business with the County in connection with the Cold Weather Shelter Partnerships contract opportunity. Effective January 1, 2024, pursuant to Florida Statutes Section 287.138(4)(a), all bidders and offerors must submit a completed affidavit with their bid or proposal if the company would receive access to personal identifying information. The affidavit requires the authorized representative of the bidding entity to confirm the company's formation location and entity type, and to affirm familiarity with the statutory requirements.
The affidavit obligates the signatory to certify under penalties of perjury that the company is not owned by the government of a Foreign Country of Concern, that no such government maintains controlling interest in the company, and that the company is neither organized under the laws of nor maintaining its principal place of business in a Foreign Country of Concern. For purposes of this affidavit, Foreign Countries of Concern include 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, and the Syrian Arab Republic, including any government agencies or entities with significant control thereof. The affidavit must be notarized before a notary public, with the notary confirming either personal knowledge or identification verification of the affiant.
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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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