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 bidding on RFP 26-0408 for Pharmacy Benefit Manager Services. The affidavit must be completed and notarized by an authorized representative of any contractor submitting a proposal to provide pharmacy benefit management services to approximately 3,200 eligible county employees. The contractor must certify that the 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, which includes the People's Republic of China, Russian Federation, Islamic Republic of Iran, Democratic People's Republic of Korea, Republic of Cuba, the Venezuelan regime of Nicolas Maduro, or the Syrian Arab Republic. The affidavit requires the contractor's signature, printed name, date, Federal Work Authorization User Identification Number, and the name and number of the Pinellas County contract. A notary public must acknowledge the affidavit either through physical presence or online notarization and provide their commission expiration date, seal, and identification of the signatory.
In addition to this Foreign Country of Concern certification, all proposing firms must complete and submit notarized affidavits addressing compliance with human trafficking laws under Florida Statute Section 787.06(14) and common carrier attestations regarding unauthorized alien transportation. The affidavit serves as a compliance mechanism under Section 287.138, Florida Statutes, ensuring that contractors meet the County's requirements regarding foreign ownership and control restrictions before being awarded any contract that would grant the entity access to personal identifying information of county employees. Contractors must submit these completed affidavits as part of their proposal package by the March 31, 2026 deadline at 3:00 p.m. through the OpenGov procurement platform.
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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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