Foreign_Countries_of_Concern_Affidavit_12.11.2025.pdf
PDF 128 KB Posted
- Attached to
- Artificial Reef - Tire Removal Project State and local contract opportunity
- Solicitation number
- 26-0349-RFP
- Issued by
- Pinellas County, Florida
About this file
This is a Foreign Country of Concern Affidavit form required by Pinellas County, Florida for contractors seeking to enter into or renew contracts that would grant access to personal identifying information. The affidavit certifies that the contractor 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 under Section 287.138, Florida Statutes. The specified 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, and the Syrian Arab Republic. An authorized representative of the contractor must complete and sign the affidavit under penalty of perjury, and the document must be notarized by a Florida notary public, with notarization conducted either through physical presence or online methods.
The affidavit form requires specific identifying information including the contractor's name, the Pinellas County contract name and number, federal work authorization user identification, and notary details including commission expiration date. A controlling interest is presumed to exist when a person or entity directly or indirectly holds voting rights of twenty-five percent or more of the company or is entitled to twenty-five percent or more of its profits. This form applies to the Artificial Reef—Tire Removal Project, a Pinellas County Solid Waste Department contract for removing approximately 3,300 tires from five artificial reef areas off the Florida coast, with recovered materials to be transported to the Artificial Reef Program Staging area at Sand Key Park in Clearwater, Florida.
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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 |
File details come from the government source that posted it. Updated .