5-Attachment E-Foreign Country of Concern.pdf

This is a Foreign Country of Concern Attestation form (PUR 1355) required by the State of Florida for entities seeking to contract with governmental entities that would provide access to Personal Identifying Information. The attestation is specifically associated with Halifax Health's procurement for three (3) NuStep T5XR Recumbent Cross Trainers to be delivered to Halifax Health Medical Center in Daytona Beach, Florida. The form must be completed and signed by an officer or representative of any bidding entity and certifies under penalties of perjury that the entity is not owned by, organized under the laws of, or has its Principal Place of Business in a Foreign Country of Concern, and that no Foreign Country of Concern government maintains a Controlling Interest in the entity.

The attestation form requires completion of standard fields including the entity name, printed name of the signatory, title, signature, and date. This certification is a prerequisite for contract award and reflects Florida's regulatory requirements under Rule 60A-1.020, F.A.C., designed to protect the security and privacy of personal identifying information that may be accessed by contractors engaged with governmental entities. All prospective vendors responding to the Halifax Health recumbent cross trainer procurement must submit a completed and signed attestation as part of their bid response.