Foreign_Countries_of_Concern_Affidavit_02.05.2025.pdf
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- Solicitation number
- 25-0590-N
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a Foreign Country of Concern Affidavit for Pinellas County, Florida, designed to ensure contractors do not have significant connections to specified foreign governments. The affidavit requires contractors to certify they are not owned by, controlled by, or principally located in countries including China, Russia, Iran, North Korea, Cuba, Venezuela, or Syria when pursuing contracts that would provide access to personal identifying information. The form must be completed by an authorized representative and notarized, with specific definitions provided for "Foreign Country of Concern" and "Controlling Interest".
The affidavit is specifically related to a sole source agreement for Thioguard (R) Magnesium Hydroxide and equipment for the William E. Dunn Water Reclamation Facility, requiring the contractor to verify compliance with Florida Statute §287.138. The document includes spaces for the contractor's signature, printed name, date, federal work authorization identification number, and the specific Pinellas County contract details. A notary section is included to formally acknowledge the contractor's attestation, with options for physical or online notarization, emphasizing the legal and regulatory requirements for government contracting in Florida.
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Text version
Foreign County of Concern Affidavit
I hereby certify that ____________________________________( the “Contractor”) is not an entity 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; nor is the entity organized under the laws of or has its principal place of business in a Foreign Country of Concern, and is otherwise in full compliance with Section §287.138, Florida Statutes.
This Affidavit must be completed by an authorized representative of the Contractor submitting a bid, proposal, reply to, or entering into, renewing, or extending, a contract with the County, which would grant the entity access to an individual’s Personal Identifying Information.
For purposes of this Affidavit:
“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.
Under penalties of perjury, I declare that I have read the foregoing affidavit and that the facts stated in it are true.
Signature: ______________________________
Print Name: ______________________________
Date: ______________________________
Federal Work Authorization User Identification No.: _____________________________
Name of Pinellas County Contract and Contract No.: ____________________________
STATE OF FLORIDA COUNTY OF ________________
The foregoing instrument was acknowledged before me by means of 1) physical presence __ or 2) online notarization___, this __________________________ (date) by ____________________________ of _____________________________________, a __________________________________ corporation, on behalf of the corporation.
He/she is personally known to me or has produced __________________________________ as identification.
[Notary Seal]
Notary Public: _________________________________________
Name typed, printed, or stamped: _________________________________________
My Commission Expires: _________________________________________
| Print Name: |
| Date: |
| Federal Work Authorization User Identification No: |
| Name of Pinellas County Contract and Contract No: |
| Notary Public: |
| Contractor Name: |
| County Name: |
| Notarization Date: |
| Name: |
| Type of Identification: |
| 1: |
| 2: |
| Notary Name: |
| Expiration Date: |
| Check Box3: Off |
| Check Box4: Off |
File details come from the government source that posted it. Updated .