Foreign_Countries_of_Concern_Affidavit.pdf
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- Solicitation number
- 26-0510-RFQ-CCNA
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This is a Foreign Countries of Concern Affidavit required by Pinellas County, Florida for contractors seeking to enter into, renew, or extend contracts that would grant access to personal identifying information. The affidavit serves as a compliance certification under Section 287.138, Florida Statutes, and applies to the 54th Avenue N Roadway Improvements project (PID 003882A), which involves engineering consulting services for developing plans, specifications, and estimates for urban roadway improvements. The project encompasses reconfiguration of a roadway segment from 49th Street N to 34th Street N, including four eleven-foot travel lanes separated by an eleven-foot center two-way left turn lane, mid-block crossing with Rectangular Rapid Flashing Beacons, signal adjustments at affected intersections, drainage improvements for stormwater management, and Right-of-Way acquisition plans.
The affidavit requires the contractor's authorized representative to certify 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 located in 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. Controlling interest is presumed when a person or entity directly or indirectly possesses voting rights or profit entitlements of twenty-five percent or more. The affidavit must be executed under penalties of perjury by an authorized representative and notarized, with the notarization conducted either through physical presence or online methods. No specific pricing, funding amounts, set-asides, or contract term information is contained in this compliance document.
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Text version
Foreign Countries 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: _________________________________________
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| Name of Pinellas County Contract and Contract No: |
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| Notarization Date: |
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| Check Box3: Off |
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