Foreign_Countries_of_Concern_Affidavit_12.11.2025.pdf
PDF 128 KB Posted
- Attached to
- 26-0408-RFP Pharmacy Benefit Manager Services
- Solicitation number
- 26-0408-REQ
- Issued by
- Pinellas County, Florida
About this file
This is a Foreign Country of Concern Affidavit required by Pinellas County, Florida for contractors bidding on or entering into contracts that would grant access to personal identifying information. The affidavit certifies that the contractor is not owned by, controlled by, or organized under the laws of any designated Foreign Country of Concern, which includes 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 signed by an authorized representative of the contractor and notarized before a notary public. This particular affidavit is associated with RFP 26-0408 for Pharmacy Benefit Manager Services, which seeks proposals from firms to provide pharmacy benefit management services for Pinellas County's 3,200 eligible employees, with services intended to be effective January 1, 2027.
The affidavit defines "Controlling Interest" as the power to direct management or policies of a company through ownership of securities, contract, or other means, with a presumption of control if a person or entity holds 25 percent or more of voting interests or is entitled to 25 percent or more of profits. Completion of this affidavit is mandatory for any contractor submitting a bid, proposal, or entering into, renewing, or extending a contract with Pinellas County that provides access to personal identifying information. The document requires the contractor to sign under penalties of perjury, provide their Federal Work Authorization User Identification Number, and have the affidavit notarized with the county name and contract number included. The notary must certify the acknowledgment through either physical presence or online notarization and provide their commission expiration date.
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Text version
Foreign Country 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 |
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