6-Attachment E-Foreign Countries of Concern (1).pdf
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- Attached to
- Ophthalmology Practice Equipment
- Solicitation number
- PROJ-25-160
- Issued by
- Volusia County, Florida
About this file
This is a Foreign Country of Concern Attestation form (PUR 1355) required by Halifax Health, a Florida governmental entity, for suppliers bidding on an Invitation to Bid for Ophthalmology Practice Equipment (PROJ-25-160). The ITB packet is available through the Halifax Health Procurement Portal beginning December 4, 2025, at 12:00 PM EST, with all questions due by December 15, 2025, at 12:00 PM EST and answered via addendum. All bids must be submitted electronically through the procurement portal with a deadline of 2:00 PM EST on December 17, 2025. Qualified suppliers with demonstrated expertise on similar projects are invited to submit bid responses for various ophthalmology practice equipment. The general conditions contained in the bid instructions will be binding upon each bidder.
The attestation requires that an officer or representative of the bidding entity certify under penalties of perjury that the entity is not owned by, organized under the laws of, does not have its Principal Place of Business in, and is not controlled by the government of a Foreign Country of Concern as defined in Florida Administrative Code Rule 60A-1.020. This certification is mandatory for any entity seeking to enter into, renew, or extend a contract with Halifax Health that would grant access to an individual's Personal Identifying Information. The form must be completed and signed with the printed name, title, and date of the authorized representative.
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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.
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