Human_Trafficking_Affidavit_02.05.2025_(3).pdf
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- Solicitation number
- 26-0361-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This is a Human Trafficking Affidavit form required by Pinellas County, Florida in accordance with Section 787.06(13) of the Florida Statutes. The affidavit applies to the Fiscal Year 2027 Pavement Preservation - Package 1 contract, which consists of four paving locations within Pinellas County totaling approximately 38.55 lane miles of roadway (two arterial and two local neighborhood projects). The form must be executed by an authorized representative of the contractor and notarized, with the affiant declaring under penalties of perjury that the contractor does not use coercion for labor or services as defined in Florida Statutes Section 787.06.
The affidavit requires the contractor to provide specific identifying information including the Federal Work Authorization User Identification Number, the name and number of the Pinellas County contract, and the contractor's legal name. The notary section requires acknowledgment by physical presence or online notarization and must include the notary's seal, commission expiration date, and identification verification method. Completion of this affidavit is a mandatory compliance requirement for all contractors submitting bids on this Pinellas County pavement preservation project.
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Text version
HUMAN TRAFFICKING AFFIDAVIT
In accordance with section 787.06 (13), Florida Statutes, the undersigned, on behalf of ____________________________ (the “Contractor”), hereby attests that the Contractor does not use coercion for labor or services as defined in Section 787.06, Florida Statutes.
The undersigned must be an authorized representative of the Contractor who can execute this affidavit on the Contractor’s behalf.
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: |
| Federal Work Authorization User Identification No: |
| Name of Pinellas County Contract and Contract No: |
| Notary Public: |
| Name typed printed or stamped: |
| My Commission Expires: |
| Contractor Name: |
| Contractor Name 1: |
| Pinellas County: |
| Date: |
| Check Box1: Yes |
| Notary Name: |
| 1: |
| 2: |
| Type of Identification: |
| Check Box2: Off |
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