Human_Trafficking_Affidavit_11.20.25.pdf
PDF 115 KB Posted
- Solicitation number
- 26-0251-REQ
- Issued by
- Pinellas County, Florida
About this file
This is a Human Trafficking Affidavit form required by Pinellas County, Florida for the Employee Benefits Concierge & Health Navigation Services contract opportunity (RFP 26-0251). The affidavit requires an authorized contractor representative 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 form must be notarized and include the contractor's name, the notary's information, the Federal Work Authorization User Identification Number, and the specific Pinellas County contract name and number. Execution of this affidavit is a mandatory compliance requirement prior to contract award, alongside other required attestations including the Foreign Countries of Concern Affidavit and Common Carrier Attestation.
This affidavit form represents one component of Pinellas County's mandatory contractor compliance and attestation requirements for the benefits concierge services procurement. Contractors responding to RFP 26-0251 must complete and submit this notarized affidavit along with evidence of E-Verify registration, Florida Division of Corporations registration, certificates of insurance, and execution of a HIPAA Business Associate Agreement. The form contains standard fields for contractor identification and notarization, with no exceptions or modifications permitted, underscoring the County's commitment to human trafficking prevention in its procurement activities.
View the file
Other files
Show all 12
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 .