7n- Affidavit 287.138 Foreign Country of Concern.pdf

CITY OF DELRAY BEACH

Affidavit Pursuant to Fla. Stat. 287.138

Florida Statute §287.138 requires all nongovernmental entities executing, renewing, or extending a contract with a governmental entity to provide an affidavit signed by an officer or representative of the nongovernmental entity under penalty of perjury that the nongovernmental entity does not meet any of the criteria in paragraphs (2)(a)-(c) of the statute. The City of Delray Beach, Florida is a governmental entity for the purposes of this statute.

As the officer or representative of the company, I certify under penalty of perjury that the company identified above:

1. is not owned by the government of a foreign country of concern;

2. the government of a foreign country of concern does not have a controlling interest in the company;

and

3. The company is not organized under the laws of and does not have its principal place of business in a foreign country of concern.

Signature: ______________________________________________________________________

(Authorized Signature)

Print Name and Title ______________________________________________________________

Date:___________________________________________________________________________

Vendor Name:

Vendor FEIN:

Vendor’s

Authorized

Representative

Name and Title:

Address:

City: State: Zip:

Phone Number:

Email Address: