Foreign_Countries_of_Concern_Affidavit_Review_Only_Do_Not_Submit_with_Your_Proposal.pdf

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 ______________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: _________________________________________