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 required by Pinellas County, Florida for the Workers Compensation Third-Party Administrator Services contract (RFP 26-0137). The affidavit serves as a certification document wherein an authorized contractor representative attests 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 requires the contractor's authorized representative to provide their signature, printed name, date, and Federal Work Authorization User Identification Number. Additionally, the affidavit must be notarized before a notary public, who must document whether the acknowledgment occurred through physical presence or online notarization and provide their commission expiration date, notary seal, and identification verification information.
The affidavit is a mandatory compliance document for contractors bidding on the Workers Compensation TPA services contract with Pinellas County. Contractors must complete and submit this form as part of their proposal package, with all required fields filled in accurately and the document properly notarized. This requirement reflects Florida's statutory obligations regarding human trafficking prevention in state and local contract procurement and applies to all vendors competing for the county's three-year workers compensation administration services contract with optional one-year renewal periods.
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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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