FORM_5_-_SCRUTINIZED_COMPANIES_CERTIFICATION.pdf
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- Solicitation number
- 2026-072-MC
- Issued by
- Lee County, Fruitville CDP, Florida
About this file
This is a Scrutinized Companies Certification form for RFQ 2026-072-MC submitted to the Lee County Port Authority in Florida. The form requires respondents to certify under penalties of perjury that their company has not been placed on the Scrutinized Companies with Activities in Sudan List, the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or the Scrutinized Companies that Boycott Israel List as defined by Florida Statutes sections 287.135 and 215.4725. Respondents must also certify that they are not engaged in business operations in Cuba and Syria, and will not engage in boycott activities against Israel during the term of any contract awarded pursuant to this Request for Qualifications.
The certification must be signed by an authorized company representative and notarized. Respondents are required to inform the Lee County Port Authority of any changes to the certified information prior to contract execution. False certification may result in contract termination, company debarment from submitting qualifications for three years, civil penalties, and assessment of attorney's fees and costs against the company. This certification applies exclusively to the Lee County Port Authority and is associated with the Progressive Design-Build for Parking Garage, Quick Turnaround Area (QTA), and Demolition/Remediation of Existing Facilities project at Southwest Florida International Airport.
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Text version
RFQ 2026-072-MC: PROGRESSIVE DESIGN-BUILD FOR PARKING GARAGE, QUICK TURNAROUND AREA (QTA), AND DEMOLITION/REMEDIATION OF EXISTING FACILITIES
FORM 5: SCRUTINIZED COMPANIES CERTIFICATION
Respondent hereby certifies under penalties of perjury as of the date of submission of its RFQ to provide goods and services to Lee County Port Authority that it has not been placed on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List as defined in section 287.135, Florida Statutes, is not engaged in business operations in Cuba and Syria; and will not engage in “Boycott Israel” activities, as defined in section 215.4725 (1)(a), Florida Statutes, that result in Respondent being placed on the Scrutinized Companies that Boycott Israel List created after October 1, 2016 and during the term of any contract awarded pursuant to this Request for Qualifications.
I further certify that I am duly authorized to submit this certification on behalf of the company as its agent and that the company is ready, willing and able to perform if awarded a contract.
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE PROCUREMENT OFFICE FOR LEE
COUNTY PORT AUTHORITY IS FOR THAT PUBLIC ENTITY ONLY AND, THAT FALSIFICATION OF
THIS CERTIFICATION MAY RESULT IN TERMINATION OF THE CONTRACT, DEBARMENT OF THE
COMPANY FROM SUBMITTING QUALIFICATIONS FOR A PERIOD OF THREE (3) YEARS FROM THE
DATE THE CERTIFICATION IS DETERMINED TO BE FALSE, CIVIL PENALTIES, AND THE
ASSESSMENT OF ATTORNEY’S FEES AND COSTS AGAINST THE COMPANY. I ALSO UNDERSTAND
THAT I AM REQUIRED TO INFORM LEE COUNTY PORT AUTHORITY PRIOR TO ENTERING INTO A
CONTRACT OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.
[Signature]
Notary Public
STATE OF ______________
COUNTY OF ____________
The foregoing instrument was signed and acknowledged before me this _______ day of _____________________, 20_____, by ____________________________________________ by means of physical presence or online notarization who produced the following as identification _________________________________ (type of identification) or is personally known to me.
My Commission Expires ________________ [stamp or seal]
[Signature of Notary Public]
[Typed or printed name]
Rev: 6.29.2026 Page 45 of 58
| COUNTY OF: |
| foregoing: |
| this: |
| means of: |
| physical presence or: |
| online notarization who produced the following as identification: |
| type of identification or is personally known to me: |
| My Commission Expires: |
| Typed or printed name: |
| Check Box7: Off |
| Check Box8: Off |
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