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
Human Trafficking Affidavit for Pinellas County Pharmacy Benefit Manager Services RFP
This document is a Human Trafficking Affidavit form required by Pinellas County Board of County Commissioners for vendors responding to RFP 26-0408 for Pharmacy Benefit Manager Services. The affidavit requires contractors to attest under penalty of perjury that they do not use coercion for labor or services as defined in Florida Statute Section 787.06. The form must be completed and signed by an authorized representative of the proposing contractor and notarized before submission. All firms submitting proposals for the PBM services contract, which will cover approximately 3,200 eligible county employees over a five-year term with two optional one-year renewal periods commencing January 1, 2027, are required to complete and submit this notarized affidavit as part of their proposal response by the March 31, 2026 at 3:00 p.m. deadline.
The affidavit includes fields for the contractor's name, the signatory's name and Federal Work Authorization User Identification Number, the Pinellas County contract name and number, the date of execution, and notary acknowledgment information including the county of acknowledgment, method of notarization (physical presence or online), notary seal, and notary commission expiration date. This compliance document serves as part of Pinellas County's vendor qualification and integrity requirements, ensuring that all proposers meet the county's human trafficking prevention standards as mandated by Florida law.
View the file
Other files
Show all 35
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 |
File details come from the government source that posted it. Updated .