Human_Trafficking_Affidavit_11.20.25.pdf
PDF 115 KB Posted
- Attached to
- 26-0408-RFP Pharmacy Benefit Manager Services
- Solicitation number
- 26-0408-REQ
- Issued by
- Pinellas County, Florida
About this file
This is a Human Trafficking Affidavit required by Pinellas County, Florida in accordance with Section 787.06(14) of the Florida Statutes for contractors bidding on the 26-0408-RFP Pharmacy Benefit Manager Services contract. The affidavit requires the authorized representative of the bidding contractor to attest under penalties of perjury that the contractor does not use coercion for labor or services as defined in Florida law. The document must be notarized and include the contractor's name, the authorized representative's signature and printed name, the date of execution, the Federal Work Authorization User Identification Number, the Pinellas County contract name and number, and notary seal and commission information.
This affidavit is a compliance document that serves as a prerequisite for contract eligibility and must be completed and submitted by any firm proposing to provide Pharmacy Benefit Management Services to Pinellas County's approximately 3,200 eligible employees. The form requires notarization by a Florida notary public who must verify the signatory's identity either through physical presence or online notarization. Contractors must ensure all required fields are completed accurately and the document is properly executed and notarized prior to proposal submission for the pharmacy benefit services contract with an intended effective date of January 1, 2027.
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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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