Attachment I PUR 1355.docx
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- Attached to
- Business Automobile Insurance
- Solicitation number
- ITB-13707
- Issued by
- Polk County, Florida
About this file
This document is an Attachment I Foreign Country of Concern Attestation form for a state or local government procurement process (PUR 1355). The form requires an officer or representative of an entity submitting a bid, proposal, or entering into a contract to certify that their organization is not owned by, organized under the laws of, or controlled by the government of a Foreign Country of Concern. The attestation is specifically designed for contracts that would grant the entity access to an individual's Personal Identifying Information.
The document provides a standard declaration template where the entity must affirm its independence from foreign government control, with space for the authorized representative to print their name, provide their title, sign the document, and date the attestation. The form is aligned with Rule 60A-1.020 of the Florida Administrative Code (F.A.C.) and is dated October 2023 (10/23), indicating it is a current procurement requirement for state or local government contracting.
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Text version
Attachment I
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) Page 1 of 1 Rule 60A-1.020, F.A.C.
File details come from the government source that posted it. Updated .