Compliance with FL Statutes Affidavit (1).pdf
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- Attached to
- Traffic Signals Replacement
- Solicitation number
- 147530
- Issued by
- Polk County, Florida
About this file
This document is a Compliance with Florida Statutes Affidavit form required for bid submissions to the Central Florida Tourism Oversight District's Procurement & Contracting Department (PO Box 690519, Orlando, FL 32869). The form addresses compliance with four primary Florida statutes and does not pertain to specific products, services, quantities, or contract timelines. Instead, it serves as a mandatory certification document that must accompany all bid responses to the District.
The affidavit requires respondents to certify compliance with FS 287.138 (prohibiting contracting with entities of foreign countries of concern including China, Russia, Iran, North Korea, Cuba, Venezuela, and Syria), FS 288.0071 (prohibiting economic incentives to foreign entities), FS 287.133 (public entity crime prohibitions and convicted vendor list restrictions), and FS 112.313 and FS 112.3143 (conflict of interest policies). Respondents must attest under penalty of perjury that they meet all statutory requirements, disclosing any affiliations with other bidders, shared ownership interests greater than 5% with District staff or officials, or conflicts of interest. False statements may result in bid rejection, debarment, and contract termination. The form requires the entity or company name, signature of an authorized officer or representative, and date of completion. No pricing terms, set-asides, funding sources, or incumbent information is specified within this compliance certification document.
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COMPLIANCE WITH FLORIDA STATUTES Completed form must be submitted with bid response.
§287.138; §288.0071; §287.133; §112.313 & §112.3143 Bid#: _________________ X
Procurement & Contracting Department PO Box 690519, Orlando, FL 32869 v.09.26 Page 1 of 4
SECTION 1. CONTRACTING WITH ENTITIES OF FOREIGN COUNTRIES OF CONCERN PROHIBITED
FS §287.138
DEFINITIONS
“Foreign country of concern” means the People’s Republic of China, the Russian Federation, the Islamic Republic of Iran, the Democratic People’s Republic of Korea, the Republic of Cuba, the Venezuelan regime of Nicolás Maduro, or the Syrian Arab Republic, including any agency of or any other entity of significant control of such foreign country of concern.
“Controlling interest” means possession of the power to direct or cause the direction of the management or policies of a company, whether through ownership of securities, by contract, or otherwise. A person or entity that directly or indirectly has the right to vote 25 percent or more of the voting interests of the company or is entitled to 25 percent or more of its profits is presumed to possess a controlling interest.
ENTITY/COMPANY INFORMATION
(References to “entity” refer to the corporation, Limited Liability Company, sole proprietor or individual submitting a bid/proposal to the Central Florida Tourism Oversight District.)
The entity must attest it does not meet any of the criteria below:
(a) The entity is owned by the government of a foreign country of concern;
(b) The government of a foreign country of concern has a controlling interest in the entity; or
(c) The entity is organized under the laws of or has its principal place of business in a foreign country of concern.
SECTION 2. ECONOMIC INCENTIVES TO FOREIGN COUNTRIES OF CONCERN PROHIBITED
FS §288.0071
DEFINITIONS
“Foreign country of concern” means the People’s Republic of China, the Russian Federation, the Islamic Republic of Iran, the Democratic People’s Republic of Korea, the Republic of Cuba, the Venezuelan regime of Nicolás Maduro, or the Syrian Arab Republic, including any agency of or any other entity of significant control of such foreign country of concern.
“Foreign entity” means an entity that is:
1. Owned or controlled by the government of a foreign country of concern; or
2. A partnership, association, corporation, organization, or other combination of persons organized under the laws of or having its principal place of business in a foreign country of concern, or a subsidiary of such entity.
“Controlled by” means having possession of the power to direct or cause the direction of the management or policies of a company, whether through ownership of securities, by contract, or otherwise. A person or entity that directly or indirectly has the right to vote 25 percent or more of the voting interests of the company or that is entitled to 25 percent or more of its profits is presumed to control the foreign entity.
“Economic incentive” means all programs administered by, or for which an applicant for the program must seek certification, approval, or other action by, the department under Florida Statutes chapter 288, chapter 212, or chapter 220; and all local economic development programs, grants, or financial benefits administered by a political subdivision or an agent thereof.
COMPANY INFORMATION
(References to “company” refer to the corporation, Limited Liability Company, sole proprietor or individual submitting a bid/proposal to the Central Florida Tourism Oversight District.)
The company must attest it is not a foreign entity.
http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0287/Sections/0287.138.html https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0288/Sections/0288.0071.html https://www.leg.state.fl.us/Statutes/index.cfm/Ch0499/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0287/Sections/0287.133.html https://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0100-0199/0112/Sections/0112.313.html https://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&URL=0100-0199/0112/Sections/0112.3143.html http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0287/Sections/0287.138.html http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0288/Sections/0288.0071.html
§287.138; §288.0071; §287.133; §112.313 & §112.3143 Bid#: _________________ X
Procurement & Contracting Department PO Box 690519, Orlando, FL 32869 v.09.26 Page 2 of 4
SECTION 3. PUBLIC ENTITY CRIME;
DENIAL OR REVOCATION OF THE RIGHT TO TRANSACT BUSINESS WITH PUBLIC ENTITIES
FS §287.133
DEFINITIONS
“Affiliate” means: (1.) A predecessor or successor of a person convicted of a public entity crime; or (2.) An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime.
The term “affiliate” includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm’s length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate.
“Convicted” or “conviction” means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.
“Convicted vendor list” means the list required to be kept by the department pursuant to paragraph (3)(d) in Florida Statutes §287.133.
“Person” means any natural person or any entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts let by a public entity, or which otherwise transacts or applies to transact business with a public entity.
The term “person” includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity.
“Public entity” means the State of Florida, any of its departments or agencies, or any political subdivision.
“Public entity crime” means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any bid, proposal, reply, or contract for goods or services, any lease for real property, or any contract for the construction or repair of a public building or public work, involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.
PUBLIC ENTITY CRIME RESTRICTIONS
A person or affiliate who has been placed on the convicted vendor list following a conviction for a public entity crime:
• may not submit a bid, proposal, or reply on a contract to provide any goods or services to a public entity;
• may not submit a bid, proposal, or reply on a contract with a public entity for the construction or repair of a public building or public work;
• may not submit bids, proposals, or replies on leases of real property to a public entity;
• may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with any public entity; and
• may not transact business with any public entity in excess of the threshold amount provided in Florida
Statutes §287.017 for CATEGORY TWO for a period of 36 months following the date of being placed on the convicted vendor list.
http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0287/Sections/0287.138.html https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0288/Sections/0288.0071.html https://www.leg.state.fl.us/Statutes/index.cfm/Ch0499/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0287/Sections/0287.133.html https://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0100-0199/0112/Sections/0112.313.html https://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&URL=0100-0199/0112/Sections/0112.3143.html https://www.leg.state.fl.us/Statutes/index.cfm/Ch0499/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0287/Sections/0287.133.html http://www.leg.state.fl.us/Statutes/index.cfm/Ch0499/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0287/Sections/0287.133.html http://www.leg.state.fl.us/Statutes/index.cfm/Ch0499/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0287/Sections/0287.017.html
§287.138; §288.0071; §287.133; §112.313 & §112.3143 Bid#: _________________ X
Procurement & Contracting Department PO Box 690519, Orlando, FL 32869 v.09.26 Page 3 of 4
SECTION 4. CONFLICT OF INTEREST POLICY
FS §112.313 and FS §112.3143
CONFLICT OF INTEREST REQUIREMENTS
All respondents must list any and all affiliations they have with other bidders/proposers, or a shared ownership interest greater than 5% with any Central Florida Tourism Oversight District (“District”) staff, District-appointed officials, or contracted persons.
After review of disclosure, employees of the District may be asked to complete a Conflict of Interest/Financial Interest Disclosure Statement.
Respondents must affirm:
• No conflict of interest exists (OR)
• Conflict of interest exists and disclose the nature of the conflict
OPTION 1 - NO CONFLICT OF INTEREST EXISTS
☐ No Conflict of Interest Exists. Per Florida Statutes §112.313 and §112.3143, the company hereby certifies that, to the best of its knowledge, no Central Florida Tourism Oversight District Board Supervisor, officer or employee, nor their spouse, child, father, mother, brother, sister, father-in-law, mother-in-law, son-in-law, daughter-in-law, or business associate, is an officer, director, partner, proprietor or employee of, or has any material interest in the company or will financially benefit from a contract between the company and the District.
OPTION 2 - CONFLICT OF INTEREST DISCLOSURE
☐ Conflict of Interest Exists. Respondents must complete the applicable sections, disclosing any and all conflicts of interest (as described above) for the bid/solicitation.
Disclose the name(s) of any employee, officer, director, shareholder, or agent of your firm that is also a District employee or public official:
Disclose the name(s) of any District employee or public official that is a known relative of an employee, officer, director, shareholder, or agent of your firm:
Disclose the name(s) of other bidders/proposers your firm is affiliated with:
COMPANY INFORMATION
(References to “company” refer to the corporation, Limited Liability Company, sole proprietor or individual submitting a bid/proposal to the Central Florida Tourism Oversight District.)
http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0287/Sections/0287.138.html https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0288/Sections/0288.0071.html https://www.leg.state.fl.us/Statutes/index.cfm/Ch0499/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0287/Sections/0287.133.html https://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0100-0199/0112/Sections/0112.313.html https://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&URL=0100-0199/0112/Sections/0112.3143.html https://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0100-0199/0112/Sections/0112.313.html https://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&URL=0100-0199/0112/Sections/0112.3143.html https://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0100-0199/0112/Sections/0112.313.html https://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&URL=0100-0199/0112/Sections/0112.3143.html
§287.138; §288.0071; §287.133; §112.313 & §112.3143 Bid#: _________________ X
Procurement & Contracting Department PO Box 690519, Orlando, FL 32869 v.09.26 Page 4 of 4
RESPONDENT (“ENTITY” OR ”COMPANY”) AFFIDAVIT
SECTION 1. FS §287.138: Contracting with Entities of Foreign Countries of Concern Prohibited I affirm the entity is not owned by the government of a foreign country of concern; the government of a foreign country of concern does not have a controlling interest in the entity; and the entity is not organized under the laws of or has its principal place of business in a foreign country of concern.
I attest under the penalty of perjury that the entity does not meet any of the foreign countries of concern criteria in Section 1, paragraphs (a)-(c) above and understand that a false statement may result in bid rejection, debarment and contract termination.
SECTION 2. FS §288.0071: Economic Incentives to Foreign Countries of Concern Prohibited I affirm the company is not a foreign entity (1) owned or controlled by the government of a foreign country of concern; or (2) a partnership, association, corporation, organization, or other combination of persons organized under the laws of or having its principal place of business in a foreign country of concern, or a subsidiary of such entity.
I attest under the penalty of perjury that the company does not meet any of the foreign entity criteria as defined above in Section 2 and understand a false statement may result in bid rejection, debarment and contract termination.
SECTION 3. FS §287.133: Public Entity Crime; Denial or Revocation of the Right to Transact Business with Public Entities I affirm neither the respondent (“company”), nor any officers, directors, executives, partners, shareholders, employee, members or agents who are active in the management of the company, nor any affiliate of the entity have been convicted of a public entity crime subsequent to July 1, 1989.
I affirm the information contained herein regarding public entity crime as defined in Section 3 is accurate and understand that a false statement may result in bid rejection, debarment and contract termination.
SECTION 4. FS §112.313 and FS §112.3143: Conflict of Interest Policy I affirm that the company: (1) has no known conflict of interest as defined in Section 4; or (2) has a known conflict of interest and disclosed all conflicts in the fields above.
I affirm the information contained herein regarding conflict of interest in Section 4 is accurate and understand that a false statement may result in bid rejection, debarment and contract termination.
Entity/Company: ___________________________________________________________________ Date: ________________
Officer/Authorized Representative Signature: ____________________________________________________________ http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0287/Sections/0287.138.html https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0288/Sections/0288.0071.html https://www.leg.state.fl.us/Statutes/index.cfm/Ch0499/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0287/Sections/0287.133.html https://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0100-0199/0112/Sections/0112.313.html https://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&URL=0100-0199/0112/Sections/0112.3143.html http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0287/Sections/0287.138.html http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0288/Sections/0288.0071.html https://www.leg.state.fl.us/Statutes/index.cfm/Ch0499/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0287/Sections/0287.133.html https://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0100-0199/0112/Sections/0112.313.html https://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&URL=0100-0199/0112/Sections/0112.3143.html
| employee or public official: |
| director shareholder or agent of your firm: |
| Disclose the names of other biddersproposers your firm is affiliated with: |
| EntityCompany Name: |
| Date: |
| Group1: Off |
| Bid: |
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