7o- Affidavit Foreign Country of Concern Disclosure (For Contracts over $100k).pdf
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- Attached to
- Marine Turtle Conservation Program Services
- Solicitation number
- RFP2025-054
- Issued by
- Palm Beach County, Florida
About this file
This document is an Affidavit from the City of Delray Beach regarding foreign country disclosure requirements for contracts or grants valued at $100,000 or more. The affidavit requires vendors to disclose any current or prior interests, contracts, grants, or gifts from foreign countries of concern with a value of $50,000 or more that existed within the past 5 years. Vendors must certify either that they have no such interests or provide detailed disclosure information.
The form mandates that vendors either affirm they have no qualifying foreign country interests or provide comprehensive details including the entity's name, mailing address, contract/grant amount, specific foreign country involved, termination or receipt dates, and the name of the source or interest holder. Additionally, vendors must submit a copy of their disclosure to the Department of Financial Services within one year before applying for a grant or proposing a contract. The document is to be signed under penalty of perjury, with space provided for vendor information, authorized representative details, and signature.
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Text version
CITY OF DELRAY BEACH
Affidavit Pursuant to Fla. Stat. Section 286.101(3)
Any entity that applies to a state agency or political subdivision for a grant or proposes a contract having a value of
$100,000 or more shall disclose to the state agency or political subdivision any current or prior interest of, any contract with, or any grant or gift received from a foreign country of concern if such interest, contract, or grant or gift has a value of $50,000 or more and such interest existed at any time or such contract or grant or gift was received or in force at any time during the previous 5 years. Such disclosure shall include the name and mailing address of the disclosing entity, the amount of the contract or grant or gift or the value of the interest disclosed, the applicable foreign country of concern and, if applicable, the date of termination of the contract or interest, the date of receipt of the grant or gift, and the name of the agent or controlled entity that is the source or interest holder. Within 1 year before applying for any grant or proposing any contract, such entity must provide a copy of such disclosure to the Department of Financial Services. As the officer or representative of the company, I certify that the Proposer and its affiliates:
1. does NOT have any current or prior interest of, any contract with, or any grant or gift received from a foreign country of concern if such interest, contract, or grant or gift has a value of $50,000 or more; and
2. has Not had prior interest of, any contract with, or any grant or gift received from a foreign country of concern within the past 5 years.
OR
3. Has provided disclosure to the City including the name and mailing address of the disclosing entity, the amount of the contract or grant or gift or the value of the interest disclosed, the applicable foreign country of concern and, if applicable, the date of termination of the contract or interest, the date of receipt of the grant or gift, and the name of the agent or controlled entity that is the source or interest holder; and
4. Has provided a copy of such disclosure to the Department of Financial Services within one year before proposing any grant or contract.
Under penalty of perjury, I declare that I have read the foregoing document, and the facts stated in it are true.
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:
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