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, applicable to the Employee Benefits Concierge & Health Navigation Services contract opportunity (26-0251-RFP). The affidavit serves as a mandatory attestation form that must be completed and notarized by an authorized representative of the contracting entity. The document requires the contractor to declare under penalties of perjury that the organization does not use coercion for labor or services as defined in Section 787.06 of the Florida Statutes.
The affidavit form requires completion of several key fields including the contractor's name, authorized representative's name and signature, Federal Work Authorization User Identification Number, the Pinellas County contract name and number, and the date of execution. A notary public must acknowledge the affidavit through either physical presence or online notarization, and must provide their commission expiration date and identification details. This compliance document is a prerequisite for contract award and must be submitted as part of the proposal package for any entity seeking to provide employee benefits concierge and health navigation services to Pinellas County employees.
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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 |
File details come from the government source that posted it. Updated .