9-Attachment E-Foreign Country of Concern.pdf

809 KB Posted

Attached to
1st Floor Pharmacy Renovation
Solicitation number
PROJ-25-098
Issued by
Volusia County, Florida

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This is a Foreign Country of Concern Attestation form (PUR 1355) required by Florida Administrative Code Rule 60A-1.020 for entities submitting bids, proposals, or replies to governmental contracts that would grant access to Personal Identifying Information. The form must be completed by an officer or representative when entering into, renewing, or extending contracts with Florida governmental entities, with the form dated October 2023.

The attestation requires entities to declare under penalty of perjury that they are not owned by the government of a Foreign Country of Concern, are not organized under the laws of or have their 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 completion of printed name, title, signature, and date fields, with the specific definitions of capitalized terms referenced in the Florida Administrative Code rule.

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8-Attachment B-Bidders Cert.pdf PDF
10-Attachment C-Human Trafficking.pdf PDF
13-ITB PROJ-25-098 1st Floor Pharmacy Renovation.pdf PDF
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5-Exhibit B - IRS Form W9.pdf PDF
6-Attachment G-Total Project Cost.pdf PDF
7-Attachment F-Subcontractors List.pdf PDF
1-Attachment A - Public Entity Crimes.pdf PDF
11-EXHIBIT 2 - 250806 COMBINED CDs Halifax Daytona - Pharmacy Renovation.pdf PDF
3-Attachment E-Foreign Country of Concern.pdf PDF
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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.

PUR 1355 1023:
Rule 60A1020 FAC:
Text1:
Text3:
Text4:

File details come from the government source that posted it. Updated .