Human_Trafficking_Affidavit_02.05.2025_(3).pdf
PDF 89 KB Posted
- Attached to
- Ridgecrest YMCA Elevator Modernization
- Solicitation number
- 26-0529-ITB-C
- Issued by
- Pinellas County, 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 document relates to the Ridgecrest YMCA Elevator Modernization project, which involves modernizing an existing 2001 KONE hydraulic elevator located at 1801 119th Street N, Largo, Florida. The affidavit serves as a certification requirement for contractors bidding on or entering into contracts with Pinellas County. The form requires an authorized representative of the contractor to attest under penalties of perjury that the contractor does not use coercion for labor or services as defined in Florida law. The affidavit must be executed by an authorized representative and notarized before submission.
The affidavit form requires completion of specific information including the contractor's name, the representative's signature and printed name, execution date, Federal Work Authorization User Identification Number, and the Pinellas County contract name and number. Notarization is mandatory and must be acknowledged before a notary public through either physical presence or online notarization, with the notary required to provide their seal, commission information, and identification verification. This human trafficking compliance document is a standard requirement for state and local contracts in Florida and serves as a safeguard to ensure contractors maintain ethical labor practices and comply with applicable state statutes regarding forced labor and coercion.
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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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