Foreign_Countries_of_Concern_Affidavit_12.11.2025.pdf
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- Attached to
- Notice of Intent to Sole Source: Uninterrupted Power Supply Battery Maintenance and Replacement Services
- Solicitation number
- 26-0024-N
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This is a Foreign Country of Concern Affidavit required by Pinellas County, Florida for contractors seeking to enter into contracts with the county that would grant access to Personal Identifying Information. The affidavit mandates that contractors certify they are not owned by the government of a Foreign Country of Concern—defined as 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—and that no such foreign government holds a Controlling Interest in the entity. Additionally, contractors must confirm the entity is not organized under the laws of or does not have its principal place of business in any Foreign Country of Concern and is in full compliance with Section 287.138, Florida Statutes. The affidavit applies to all contractors submitting bids, proposals, or replies to Pinellas County contracts involving personal information access.
The affidavit must be completed and signed by an authorized representative of the contractor under penalties of perjury and requires notarization in the state of Florida. Contractors must provide their Federal Work Authorization User Identification Number, the Pinellas County contract name and contract number, and details of the notarization, including the notary public's commission expiration date. The document serves as a compliance verification mechanism to ensure contractors meet statutory requirements regarding foreign ownership and control restrictions before being awarded county contracts that provide access to sensitive personal identifying information.
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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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