Human_Trafficking_Affidavit_11.20.25.pdf
PDF 115 KB Posted
- Solicitation number
- 26-0137-REQ
- 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(14) of the Florida Statutes, for the Workers Compensation Third Party Administrator Services contract (26-0137-RFP). The affidavit serves as a mandatory attestation that must be executed by an authorized representative of the contracting entity, confirming that the Contractor does not engage in coercion for labor or services as defined under Florida law. The form requires the authorized signatory to declare under penalties of perjury that the information provided is accurate and true.
The affidavit must be notarized before a Notary Public and includes fields for the contractor's name, Federal Work Authorization User Identification Number, the specific Pinellas County contract name and number, the notary's seal and commission expiration date, and the date of notarization. The form can be executed through either physical presence or online notarization. This document is a standard compliance requirement for state and local contracting in Florida and does not contain pricing terms, service specifications, or other substantive contract provisions.
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Text version
HUMAN TRAFFICKING AFFIDAVIT
In accordance with section 787.06 (14), 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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