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 form required by Pinellas County, Florida for contractors seeking to provide Pharmacy Benefit Manager (PBM) Services under RFP 26-0408. The affidavit requires authorized contractor representatives to certify that their entity is not owned by, does not have a controlling interest held by, and is not organized under the laws of or principally located in a Foreign Country of Concern, as defined under Florida Statutes Section 287.138. The countries and regimes specified as 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, and the Syrian Arab Republic. A Controlling Interest is defined as the power to direct management or policies through ownership of securities or contract, with a presumption of control at 25 percent or more of voting interests or profit entitlement. The affidavit must be completed, signed under penalty of perjury by an authorized contractor representative, notarized, and submitted as part of the proposal response for any entity that would receive access to personal identifying information through the contract.
The form requires execution before a notary public and includes fields for the contractor name, Federal Work Authorization User Identification Number, Pinellas County contract name and number, notary identification and commission expiration date, and the notarization date. Contractors must certify their compliance with these ownership restrictions as a condition of bid submission, with the affidavit serving as a compliance verification document alongside other required attestations regarding human trafficking laws and common carrier requirements. Failure to complete and submit the notarized affidavit constitutes non-compliance with contract eligibility requirements for the PBM Services procurement.
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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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