6-Form - Scrutinized.pdf
PDF 77 KB Posted
- Attached to
- Annual Bid to Furnish and Deliver Polymer
- Solicitation number
- 2027002
- Issued by
- Indian River County, Florida
About this file
This is a Certification Regarding Prohibition Against Contracting with Scrutinized Companies form required for submission with bids and proposals to Florida counties. The certification requires respondents to confirm that neither they nor any wholly owned subsidiaries, majority-owned subsidiaries, parent companies, or affiliates have been placed on the Scrutinized Companies that Boycott Israel List or are engaged in boycotts of Israel. For contracts valued at one million dollars or more, respondents must additionally certify that they and related entities are not on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, and are not engaged in business operations in Cuba or Syria as defined under Florida Statutes sections 215.4725 and 215.473.
The form requires the authorized representative of the responding company to sign and date the certification, providing the respondent name, signatory name and title. Counties reserve the right to immediately terminate any resulting contract upon written notice if the undersigned entity or related entities are found to have submitted false certification or are subsequently placed on any of the aforementioned scrutinized companies lists, engaged in prohibited boycotts, or found to be conducting business operations in the restricted jurisdictions. This certification applies to the Annual Bid to Furnish and Deliver Polymer for the period October 1, 2026, through September 30, 2027.
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Text version
CERTIFICATION REGARDING PROHIBITION AGAINST
CONTRACTING WITH SCRUTINIZED COMPANIES
(This form MUST be submitted with your bid/proposal/SOQ)
I hereby certify that neither the undersigned entity, nor any of its wholly owned subsidiaries, majority-owned subsidiaries, parent companies, or affiliates of such entities or business associations, that exists for the purpose of making profit have been placed on the Scrutinized Companies that Boycott Israel List created pursuant to s. 215.4725 of the Florida Statutes, or are engaged in a boycott of Israel.
In addition, if this solicitation is for a contract for goods or services of one million dollars or more, I hereby certify that neither the undersigned entity, nor any of its wholly owned subsidiaries, majority-owned subsidiaries, parent companies, or affiliates of such entities or business associations, that exists for the purpose of making profit are on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, created pursuant to s. 215.473 of the Florida Statutes, or are engaged in business operations in Cuba or Syria as defined in said statute.
I understand and agree that the County may immediately terminate any contract resulting from this solicitation upon written notice if the undersigned entity (or any of those related entities of respondent as defined above by Florida law) are found to have submitted a false certification or any of the following occur with respect to the company or a related entity: (i) it has been placed on the Scrutinized Companies that Boycott Israel List, or is engaged in a boycott of Israel, or (ii) for any contract for goods or services of one million dollars or more, it has been placed on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or it is found to have been engaged in business operations in Cuba or Syria.
Name of Respondent: ___________________________________
By: ________________________________________________ (Authorized Signature)
Name:
Title: ______________________________________________
Date:_____________________________
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