Human_Trafficking_Affidavit_02.05.2025.pdf
PDF 89 KB Posted
- Attached to
- Pinellas County Health Program Evaluation Services State and local contract opportunity
- Solicitation number
- 25-0913-RFP
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This is a Human Trafficking Affidavit required by Pinellas County, Florida for contractors bidding on the county's Health Program Evaluation Services contract. The affidavit is a compliance document that obligates the contractor to attest, under penalties of perjury, that it does not use coercion for labor or services as defined in Section 787.06 of Florida Statutes. The document must be executed by an authorized representative of the contractor and notarized before a Florida notary public. The affidavit requires the signatory to provide their printed name, date of execution, Federal Work Authorization User Identification Number, and the name and number of the Pinellas County contract. The notary must acknowledge the execution through either physical presence or online notarization, verify the identity of the representative, and affix their commission seal along with signature, typed or printed name, and expiration date of their notarial commission.
This affidavit is one of several compliance documents required by Pinellas County for the Health Program Evaluation Services procurement, along with a HIPAA Business Associate Agreement, Common Carrier Attestation, and a Foreign Countries of Concern Affidavit. The human trafficking attestation requirement reflects the county's commitment to ethical procurement practices and labor compliance. All vendors responding to the Request for Proposal, which had a proposal deadline of October 2, 2025, at 3:00 pm, must complete and submit this notarized affidavit as part of their proposal package to be considered for the six-month contract term with no renewal options.
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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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