Foreign_Countries_of_Concern_Affidavit_12.11.2025.pdf
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- Solicitation number
- 26-0655-REQ
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This is a Foreign Country of Concern Affidavit form required by Pinellas County Board of County Commissioners, Florida for contractors bidding on or entering into contracts with the County that would grant access to Personal Identifying Information. The affidavit requires contractors to certify they are not owned by or do not have a controlling interest held by governments of designated foreign countries of concern, which are 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. The form must be completed by an authorized representative of the bidding entity and notarized, with the contractor required to declare under penalties of perjury that the stated facts are true. A controlling interest is defined as direct or indirect possession of the power to direct management or policies through ownership of securities, contract, or other means, with a presumption of controlling interest if a person or entity directly or indirectly holds voting rights or profit entitlement of 25 percent or more.
The affidavit form includes fields for the contractor's name, signature, date, Federal Work Authorization User Identification Number, Pinellas County contract name and number, and detailed notarization information including the notary public's seal, commission expiration date, and identification verification method. This requirement is part of compliance with Section 287.138, Florida Statutes, and applies to all contractors seeking access to personal identifying information through county contracts, including the third-party administration services for Medicare Advantage plans referenced in the related RFP (26-0655-RFP).
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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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