Contractor's Statutory Compliance Affidavit.pdf

Contractors Affidavit v.1.00 Page | 1 rev 6/2024

CONTRACTOR’S STATUTORY COMPLIANCE AFFIDAVIT

I, _____________________________________, am an officer or authorized representative of the business entity shown below. I hereby acknowledge on behalf of my business or business entity that I am aware that governmental entities of the State of Florida are prohibited from entering into, amending, extending, and renewing certain contracts and agreements with foreign countries of concern, pursuant to section 287.138, Florida Statutes, business entities that engage in forced labor and human trafficking practices, pursuant to sections 287.1346, and 786.06(13), Florida Statutes.

Business or Business Entity Legal Name:

Business or Business Entity Legal Address:

Business or Business Entity Taxpayer Identification Number:

I hereby certify under penalty of perjury that:

• My business entity is not owned by a foreign country of concern, as defined by section 287.138, Florida Statutes.

• No foreign country of concern has a controlling interest in my business entity, as defined by section 287.138, Florida Statutes.

• My business entity is not organized under the laws of or has its principal place of business in a foreign country of concern as defined by section 287.138, Florida Statutes.

• My business entity does not engage in forced labor practices, as defined by section 287.1346, Florida Statutes.

• My business entity does not engage in human trafficking, as defined by section 787.06, Florida Statutes.

• My business entity does not employ or engage any person who performs any of the activities in section 787.30, Florida Statutes.

I have been advised that, in addition to criminal penalties for perjury for providing false information on this affidavit, my failure to comply with the requirements of sections 287.1346 and 287.138, and chapter 787, Florida Statutes, may result in civil and criminal penalties, prohibitions against doing business with any governmental entity of the State of Florida the suspension or revocation of all business or professional licenses and certifications issued by the State of Florida.

Contractors Affidavit v.1.00 Page | 2 rev 6/2024

By signing this affidavit, I agree that I will notify the Contract Manager within ten (10) calendar days of any change in my business entity status that would make any statement made on this affidavit untrue and within thirty (30) calendar days of gaining direct knowledge that any subcontractor or vendor is in violation of any of the requirements of sections 287.1346 and 787, Florida Statutes. I further acknowledge that the failure to make the appropriate notification will result in the immediate termination of my contract.

I HEREBY AFFIRM AND VERIFY THAT THE FOREGOING IS TRUE AND CORRECT.

Sole Proprietor/Authorized Representative

Printed Name

STATE OF _______________________

COUNTY OF _____________________

Sworn to (or Affirmed) and Subscribed Before Me By Means of ☐ Physical Presence or ☐ Online Notarization this ___________ day of __________________, 202__, by ________________________________________, Who ☐ Is Personally Known to Me or ☐ Produced Identification.

Type of Identification Produced: _________________________

Signature of Notary Public

Printed Name of Notary Public Administering Oath Pursuant to §117.03, Florida Statutes