7-Attachment E-Foreign Countries of Concern.pdf

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Attached to
Vein Finder for HMC Oncology
Solicitation number
PROJ-26-045
Issued by
Volusia County, Florida

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This is a Foreign Country of Concern Attestation form (PUR 1355) required by the State of Florida for vendors submitting bids or proposals to Halifax Health for a Vein Finder for HMC Oncology. The attestation must be completed by an authorized officer or representative of any entity seeking to enter into, renew, or extend a contract with a governmental entity that would provide access to an individual's Personal Identifying Information.

The vendor must certify under penalties of perjury that the entity is not owned by the government of a Foreign Country of Concern, is not organized under the laws of a Foreign Country of Concern, does not have its Principal Place of Business in a Foreign Country of Concern, and that the government of a Foreign Country of Concern does not have a Controlling Interest in the entity. The form requires the vendor to provide the entity name, printed name of the signatory, title, signature, and date of attestation. This certification is mandated under Rule 60A-1.020, F.A.C., and must be submitted as part of the bid or proposal response.

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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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