Foreign_Countries_of_Concern_Affidavit_02.05.2025.pdf
PDF 115 KB Posted
- Attached to
- Pinellas County Health Program Evaluation Services State and local contract opportunity
- Solicitation number
- 25-0913-RFP
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This is a Foreign Countries of Concern Affidavit document required by Pinellas County, Florida for contractors seeking to enter into contracts that would provide access to individuals' Personal Identifying Information. The affidavit requires authorized contractor representatives to certify that their entity is not owned by, does not have a controlling interest from, and is not organized under the laws of or principally located in a Foreign Country of Concern, as defined by Section 287.138 of Florida Statutes. Specifically, foreign countries of concern include 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 completed and notarized prior to contract execution, with a controlling interest presumed to exist when a person or entity directly or indirectly holds voting rights or profit entitlements of 25 percent or more.
The affidavit requires completion of multiple fields including the contractor's name, authorized representative's signature and printed name, date of execution, Federal Work Authorization User Identification Number, the specific Pinellas County contract name and number, and notarization information. The notary public must acknowledge the contractor's representative either through physical presence or online notarization and must include their commission expiration date, seal, and signature. This compliance documentation is mandatory for all vendors responding to Pinellas County's Request for Proposal for Health Program Evaluation Services, which closed on October 2, 2025, and establishes a contractual requirement that extends throughout the six-month contract term with no renewal options.
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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 .