Form_9.10_-_Scrutinized_Companies_Certification.pdf

FORM 9.10 SCRUTINIZED COMPANIES CERTIFICATION

(To be signed in the presence of a notary public or other of�icer authorized to administer oaths.)

SCRUTINIZED COMPANIES CERTIFICATION PURSUANT TO SECTION 287.135, FLORIDA STATUTES

I, ____________________________________________________________________________________________________________, on behalf (Print Name and Title) of____________________________________________________ (“Company”), certify that __________________________________________ (Company Name) (Company Name) does not: 1. Participate in a boycott of Israel; and

2. Is not on the Scrutinized Companies with Boycott Israel List; and

3. Is not on the Scrutinized Companies with Activities in Sudan List; and

4. Is not on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List; and

5. Has not engaged in business operations in Syria.

Submitting a false certi�ication shall be deemed a material breach of contract. The City of Port Orange shall provide notice, in writing, to the Company of the City’s determination concerning the false certi�ication. The Company shall have ninety (90) days following receipt of the notice to respond in writing and demonstrate that the determination of false certi�ication was made in error. If the Company does not demonstrate that the City’s determination of false certi�ication was made in error, then the City shall have the right to terminate the contract and seek civil remedies pursuant to Florida Statute § 287.135.

Section 287.135, Florida Statutes prohibits the City from: 1) Contracting with companies for goods or services in any amount if at the time of bidding on, submitting a proposal for, or entering into or renewing a contract if the company is on the Scrutinized Companies that Boycott Israel List, created pursuant to Section 215.4725, F.S. or is engaged in a boycott of Israel; and 2) Contracting with companies for goods or services over $1,000,000.00 that are on either the Scrutinized Companies with activities in the Iran Petroleum Energy Sector List, created pursuant to s. 215.473, or are engaged in business operations in Syria.

As the person authorized to sign on behalf of the Company, I hereby certify that the company identi�ied above in the section entitled “Company Name” does not participate in any boycott of Israel, is not listed on the Scrutinized Companies that Boycott Israel List, is not listed on either the Scrutinized Companies with activities in the Iran Petroleum Energy Sector List and is not engaged in business operations in Syria. I understand that pursuant to Section 287.135, Florida Statutes, the submission of a false certi�ication may subject the company to civil penalties, attorney’s fees, and/or costs. I further understand that any contract with the City for goods or services may be terminated at the option of the City if the company is found to have submitted a false certi�ication or has been placed on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List.

COMPANY NAME SIGNATURE

PRINT NAME TITLE

STATE OF FLORIDA COUNTY OF: _____________________________________

The foregoing instrument was acknowledged before me by means of ☐physical presence or ☐online notarization, this _________ day of _______________________, 2025, by____________________________________________________________ and who:

☐Is personally known to me; or ☐ has produced __________________ as identification.

____________________________________________________Notary Public, State of ______________________________________ Printed, typed or stamped name, commission and expiration:

This document to be completed and returned with your Submittal