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 form required by Pinellas County, Florida for the Health Program Evaluation Services contract opportunity. The affidavit requires an authorized representative of the contracting firm to attest under penalties of perjury that the contractor does not use coercion for labor or services as defined in Section 787.06 of the Florida Statutes. The document must be notarized and includes fields for the contractor's name, Federal Work Authorization User Identification number, Pinellas County contract name and number, notary information, and the date of notarization. The form accommodates both physical presence and online notarization options for the notary acknowledgment.
This affidavit is a mandatory compliance requirement for vendors responding to Pinellas County's Request for Proposal for comprehensive evaluation services of the Pinellas County Health Program and Healthcare for the Homeless Program. Contractors must execute and notarize this document as part of their proposal submission. The affidavit serves as a verification of the contractor's compliance with Florida's human trafficking statutes and is one of several required documentation items, alongside a HIPAA Business Associate Agreement, Common Carrier Attestation, and Foreign Countries of Concern Affidavit. All proposals were due by October 2, 2025, at 3:00 pm, and the resulting contract term is six months 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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