Foreign_Countries_affidavit_9.23.25.pdf
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- Attached to
- Equitable Services for Private Schools
- Solicitation number
- 019-MJ-0326
- Issued by
- Polk County, Florida
About this file
This is an affidavit form required by the State of Florida for vendor compliance with Section 287.138, Florida Statutes, applicable to the School Board of Polk County, Florida's Equitable Services for Private Schools procurement. The affidavit must be completed and notarized by an authorized representative of any vendor seeking to enter into a contract with the District that may grant or allow access to personal identifying information. The form requests standard vendor information including name, address, phone number, and authorized representative details.
The affidavit requires the vendor to certify under penalty of perjury that the company is not owned by, does not have controlling interest from, and is not organized under the laws of or principally located in seven designated foreign countries of concern: 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 Nicolas Maduro, or the Syrian Arab Republic. The document must be signed by an authorized company representative and notarized, with the notary public verifying the representative's identity through personal knowledge or government-issued identification. This certification became effective January 1, 2024, and is a mandatory prerequisite for contract eligibility with Florida governmental entities handling personal identifying information.
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Text version
Affidavit Regarding Foreign Countries of Concern
State of Florida County of __________________
Name of Vendor: _____________________________________________________________________
Address: ____________________________________________________________________________
Phone Number: ______________________________________________________________________
Authorized Representative’s Name: _____________________________________________________
Authorized Representative’s Title: _______________________________________________________
Effective January 1, 2024, Section 287.138, Florida Statutes, prohibits a Florida governmental entity from entering into a contract that may grant or allow access to any individual’s personal identifying information unless the contracting entity furnishes an affidavit signed by an officer or representative under penalty of perjury concerning foreign countries of concern.
As the person authorized to sign on behalf of the vendor, I certify that:
• The vendor is not owned by 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, or by any agency of or any other entity of significant control of any of such foreign country of concern.
• The government of 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 does not have a controlling interest in the vendor.
• The vendor is not organized under the laws of and does not have its principal place of business in 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.
Under penalty of perjury, I declare that I have read the foregoing document and that the facts stated in it are true.
Signature of Authorized Representative: _______________________________________________
The foregoing instrument was acknowledged before me this _____ day of _____, 20____, by _________________________, as Authorized Representative of the above-named Vendor who is (___) personally known to me or (____) produced a _______ driver’s license as identification.
Notary Public, State of _____________________ Commission no.: __________________________ My commission expires:____________________
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