Foreign_Countries_of_Concern_Affidavit_12.11.2025.pdf
PDF 128 KB Posted
- Attached to
- Indigent Burial and Cremation Services
- Solicitation number
- 26-0292-RFP
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This is a Foreign Countries of Concern Affidavit required by Pinellas County, Florida, for the Indigent Burial and Cremation Services procurement (RFP 26-0292-RFP). The affidavit serves as a compliance document that must be completed and notarized by an authorized representative of any contractor submitting a bid, proposal, or entering into a contract with the county that would grant access to an individual's Personal Identifying Information. The contractor must certify under penalties of perjury that the entity is not owned by, does not have a controlling interest held by, and is not organized under the laws of or principally based in any designated Foreign Country 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. "Controlling Interest" is defined as possession of the power to direct management or policies, including direct or indirect ownership or entitlement to 25 percent or more of voting interests or profits.
The affidavit requires the contractor to provide specific identifying information including the contractor name, Federal Work Authorization User Identification Number, the name and number of the Pinellas County contract, and the signature and printed name of an authorized representative along with the date of execution. The document must be notarized by a Florida notary public who certifies acknowledgment through either physical presence or online notarization, and the notary must provide their commission expiration date, name, and seal. This affidavit is a mandatory compliance requirement for all bidders seeking to qualify for award under the indigent burial and cremation services contract, which has an estimated annual funding not to exceed $550,000 with a contract term of five years from the date of award.
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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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