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 required by Pinellas County, Florida for contractors seeking to conduct health program evaluation services. The affidavit certifies that the contractor is not owned by or under the controlling interest of governments designated as Foreign Countries of Concern, which 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 affidavit must be completed and notarized by an authorized representative of any contractor submitting a bid or proposal for a Pinellas County contract that would grant access to an individual's Personal Identifying Information. The form requires the contractor's signature, printed name, date, Federal Work Authorization User Identification Number, contract name and number, and notarization by a public notary with documented identification of the signatory.
The affidavit defines "Controlling Interest" as the power to direct management or policies through ownership, contract, or other means, with a presumption of control if a person or entity directly or indirectly possesses voting rights or profit entitlement of 25 percent or more. Submission of the completed affidavit constitutes a declaration under penalties of perjury that the facts stated are true. This compliance requirement applies to the Pinellas County Health Program Evaluation Services RFP, for which proposals were due October 2, 2025, and the six-month contract term includes 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: _________________________________________
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| 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: |
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| Notary Name: |
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| Check Box3: Off |
| Check Box4: Off |
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