Foreign_Countries_of_Concern_Affidavit_12.11.2025.pdf
PDF 128 KB Posted
- Solicitation number
- 26-0251-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 Request for Proposal 26-0251 for employee benefits concierge and health navigation services. The affidavit certifies that the contractor is not owned by or does not have a controlling interest held by the governments of specified foreign countries of concern, including 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 form must be completed and signed by an authorized representative of any contractor submitting a proposal to access personal identifying information in connection with the County contract. The affidavit requires notarization and includes spaces for the contractor's name, signature, date, federal work authorization user identification number, contract name and number, notary seal, and notary public certification and expiration date. The document is executed under penalties of perjury in accordance with Section 287.138, Florida Statutes.
This affidavit represents a mandatory compliance requirement for all contractors responding to Pinellas County's RFP for benefits concierge and health navigation services. Contractors who fail to complete and execute the affidavit with proper notarization will be unable to proceed with contract negotiations or award. The requirement applies uniformly to all potential bidders regardless of organizational type or status and is part of a broader set of mandatory attestations and certifications that contractors must provide, including HIPAA Business Associate Agreements, Human Trafficking Affidavits, and Common Carrier Attestations. The foreign country of concern restriction reflects Florida's statutory compliance framework designed to protect sensitive personal data accessed through state and local government contracts.
View the file
Other files
Show all 12
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .