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 required by Pinellas County, Florida in accordance with Section 787.06(14) of the Florida Statutes as part of the procurement process for Request for Proposal 26-0251 for Employee Benefits Concierge & Health Navigation Services. The affidavit requires the Contractor's authorized representative 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 includes fields for the contractor name, Pinellas County contract number, Federal Work Authorization User Identification Number, notary information, and identification type. The affidavit serves as a mandatory certification requirement that all contractors must execute prior to award of the contract for employee benefits concierge and health navigation services.
This attestation is one of several mandatory certifications required of all responding contractors for the RFP, which include the Foreign Countries of Concern Affidavit, Common Carrier Attestation, and HIPAA Business Associate Agreement compliance. Contractors must also comply with Florida Division of Corporations registration requirements, E-Verify verification, and provide certificates of insurance with specified coverage limits prior to contract award. The RFP evaluation process will be based on qualifications, approach, statement of work, compensation, and exceptions to the RFP requirements, with proposals limited to 50 pages and submission required by March 5, 2026, at 3:00 p.m. via the OpenGov procurement portal. The initial contract term is five years effective August 1, 2026, with two optional twelve-month renewal periods subject to mutual agreement.
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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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