Attachment_B_-_QUALIFICATIONS_FORM_2.pdf

Attachment B

QUALIFICATIONS FORM 2

AFFIDAVIT FROM RESPONDENT

STATE OF FLORIDA

PINELLAS COUNTY

BEFORE ME, the undersigned authority, personally came and appeared _____________________ , who after being by me duly sworn, deposed and said that he/she is a fully authorized representative of (hereinafter referred to as “Respondent”) the party who has prepared the Statement Of Qualifications for the management, operation and maintenance of the resource recovery facility for Pinellas County, which Statement Of Qualifications will be received by Pinellas County on _____________ ___, 20____ and said affiant further stated:

1) That Respondent employed no person, corporation, firm, association, or other organization, (“person”) either directly or indirectly, to secure the public contract under which such person received payment, other than persons regularly employed by the Respondent whose services in connection with the project or in securing the public contract were in the regular course of their duties for Respondent.

2) I further warrant that no person or selling agency has been employed or retained to solicit or secure such contract upon an agreement or understanding for a commission, percentage, brokerage or contingent fee, except bona fide employees or bona fide established commercial or selling agencies maintained by the Respondent.

3) That if the Respondent is awarded the contract, that no part of the price to be received by the Respondent was or will be paid to any person, corporation, firm, association, or other organization for soliciting the contract, other than the payment of their normal compensation to persons regularly employed by the Respondent whose services in connection with the project were in the regular course of their duties for Respondent.

4) Said Statement of Qualifications is genuine and the Respondent has not colluded, conspired, or agreed directly or indirectly with any other Respondent to offer a sham or collusive Statement of Qualifications. I understand that collusive bidding and all similar activity is a violation of County, state, and federal law, and can result in fines, prison sentences and civil damages. I agree to abide by all conditions of this procurement and our Statement of Qualifications, and certify that I am authorized to sign for this Respondent.

5) Said Respondent has not in any manner directly or indirectly agreed with any other persons to fix the proposal price of affiant or any other Respondent, or to fix any overhead profit or cost element of said proposal price, or that of any other Respondent, or to induce any other person to refrain from proposing

Qualifications Form 2

Attachment B

6) Said Statement of Qualifications is not intended to secure an unfair advantage of benefit from Pinellas County or in favor of any person interested in the proposed contract.

7) All statements contained in said Statement of Qualifications are true, correct and complete.

8) Said Respondent hereby certifies that no officer of the companies comprising the Respondent, or any affiliates of the companies comprising the Respondent, has been convicted of fraud by the federal government or by any government entity in Florida or any other state within the last ten years.

9) Neither affiant nor any member of his company has divulged information regarding said Statement of Qualifications or any data relative thereto to any other person, firm, or corporation.

10) Said Respondent hereby certifies that neither the Respondent nor its parent is in Chapter 11 Bankruptcy nor is the Respondent or its parent in Chapter 7 Bankruptcy.

11) Said Respondent hereby certifies that neither the Respondent nor its parent nor its affiliates is involved in a lawsuit with Pinellas County.

12) Said Respondent hereby certifies that Respondent, its parent and all affiliates are, in all respects, in compliance with the Florida Public Entities Crime Act found at Florida Statutes s.287.133.

13) Said Respondent hereby certifies the truth and accuracy of the above statements under the pains and penalties of perjury.

14) I acknowledge receipt of addenda:

Number Date

(Signature of Respondent)

(Printed Name and Title)

SWORN TO AND SUBSCRIBED

BEFORE ME THIS DAY OF , 20____

(SEAL)

NOTARY PUBLIC IN AND FOR THE STATE OF __________

Qualifications Form 2