FORM 12-PUR 1355 FOREIGN COUNTRY OF CONCERN ATTESTATION.pdf
PDF 238 KB Posted
- Attached to
- MyFloridaNet-3 Core Services - ITN
- Solicitation number
- ITN-12980
- Issued by
- Clay County, Leon County, Polk County, Florida
About this file
This document is a Foreign Country of Concern Attestation form (PUR 1355) issued by the Florida Department of Management Services for the MyFloridaNetwork-3 Core Services Invitation to Negotiate (ITN No.: DMS-24/25-260). The form is designed for entities submitting bids, proposals, or replies to contracts with governmental entities that would grant access to personal identifying information. The attestation requires an officer or representative to declare that their organization is not owned, organized, or controlled by the government of a Foreign Country of Concern.
The form mandates that the completing entity affirm under penalties of perjury that they are not owned by a foreign government, not organized under the laws of a Foreign Country of Concern, do not have their principal place of business in such a country, and that no foreign government has a controlling interest in the organization. Blank fields are provided for the printed name, title, signature, and date of the attesting individual, indicating this is a standard compliance document to be completed by bidders on the MyFloridaNetwork-3 project.
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Text version
ITN No.: DMS-24/25-260 Page 1 of 2 MyFloridaNet-3 Core Services
FORM 12 – PUR 1355 FOREIGN COUNTRY OF CONCERN ATTESTATION
4050 Esplanade Way Tallahassee, FL 32399-0950
850-488-2786
Ron DeSantis, Governor Pedro Allende, Secretary
FORM 12 – PUR 1355 FOREIGN COUNTRY OF CONCERN ATTESTATION
FOR
MyFloridaNetwork-3
ITN NO: DMS-24/25-260
THE STATE OF FLORIDA
DEPARTMENT OF MANAGEMENT SERVICES
ITN No.: DMS-24/25-260 Page 2 of 2 MyFloridaNet-3 Core Services
FORM 12 – FOREIGN COUNTRY OF CONCERN ATTESTATION
FOREIGN COUNTRY OF CONCERN ATTESTATION
(PUR 1355)
This form must be completed by an officer or representative of an entity submitting a bid, proposal, or reply to, or entering into, renewing, or extending, a contract with a Governmental Entity which would grant the entity access to an individual’s Personal Identifying Information. Capitalized terms used herein have the definitions ascribed in Rule 60A-1.020, F.A.C.
Name of entity is not owned by the government of a Foreign Country of Concern, is not organized under the laws of nor has its Principal Place of Business in a Foreign Country of Concern, and the government of a Foreign Country of Concern does not have a Controlling Interest in the entity.
Under penalties of perjury, I declare that I have read the foregoing statement and that the facts stated in it are true.
Printed Name:
Title:
Signature: Date:
https://www.flrules.org/gateway/RuleNo.asp?title=GENERAL%20REGULATIONS&ID=60A-1.020
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