Affidavit Regarding Labor & Services.pdf

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Attached to
CLOUD BASED ARTERIAL MANAGEMENT (CBAM) REGIONAL PLATFORM FOR TREASURE COAST FOR FLORIDA DEPARTMENT
Solicitation number
ITB-12314
Issued by
Broward County, Fruitville CDP, Florida

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The document is an Affidavit Regarding Labor and Services form issued by the State of Florida Department of Transportation, effective July 1, 2024. The form requires nongovernmental entities entering into, renewing, or extending contracts with governmental entities to provide an affidavit attesting that they do not use coercion for labor or services, as defined in §787.06, Florida Statutes.

The affidavit must be signed by an authorized representative of the nongovernmental entity under penalty of perjury, and it requires the entity to provide details such as their name, address, phone number, authorized representative's name and title, and email address. The document includes spaces for signatures, notarization, and confirmation of identification, ensuring a legally binding declaration that the entity does not engage in coercive labor practices.

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STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

AFFIDAVIT REGARDING LABOR AND SERVICES

375-030-31

PROCUREMENT

07/24

Effective July 1, 2024, pursuant to §787.06(13), Florida Statutes, when a contract is executed, renewed, or extended between a nongovernmental entity and a governmental entity, the nongovernmental entity must provide the governmental entity with an affidavit signed by an officer or a representative of the nongovernmental entity under penalty of perjury attesting that the nongovernmental entity does not use coercion for labor or services.

Nongovernmental Entity's Name:

Address:

Phone Number:

Authorized Representative’s Name:

Authorized Representative’s Title:

Email Address:

AFFIDAVIT

I, insert nongovernmental entity's authorized representative name, as authorized representative attest that insert nongovernmental entity's namedoes not use coercion for labor or services as defined in §787.06, Florida Statutes.

Under penalty of perjury, I declare that I have read the foregoing Affidavit and that the facts stated in it are true.

(Signature of authorized representative) Date

STATE OF FLORIDA

COUNTY OF

Sworn to (or affirmed) and subscribed before me, by means of physical presence or online notarization, this day of , (year), by

Notary Public, not required when digital

Commission Expires Personally Known OR Produced Identification Type of Identification Produced

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