Foreign_Countries_of_Concern_Affidavit-_FOR_EXAMPLE_ONLY.pdf
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- Solicitation number
- 26-0494-RFQ-CCNAC
- Issued by
- Pinellas County, Florida
About this file
This is a Foreign Country of Concern Affidavit required by Pinellas County, Florida for contractors bidding on professional engineering services under the Consultants' Competitive Negotiation Act (CCNA). The affidavit 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 the entity access to an individual's Personal Identifying Information. The contractor must certify that it is not owned by the government of a Foreign Country of Concern, that such a government does not have a Controlling Interest in the entity, and that the entity is not organized under the laws of or does not have its principal place of business in a Foreign Country of Concern. For purposes of this requirement, Foreign Countries of Concern 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, and the Syrian Arab Republic, including any agency or entity of significant control thereof.
The affidavit requires the contractor's authorized representative to sign under penalties of perjury and must be notarized before a notary public who verifies the signatory's identity through physical presence or online notarization. The completed form must include the contractor's name, Federal Work Authorization User Identification Number, the name and contract number of the Pinellas County contract, the notarization date, and the notary public's commission expiration date. This compliance requirement is mandated by Section 287.138, Florida Statutes, and applies to all contractors seeking to access Personal Identifying Information through county contracts.
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Text version
Foreign County 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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