Human_Trafficking_Affidavit_11.20.25.pdf
PDF 115 KB Posted
- Attached to
- Notice of Intent to Sole Source: Uninterrupted Power Supply Battery Maintenance and Replacement Services
- Solicitation number
- 26-0024-N
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This is a Human Trafficking Affidavit form required by Pinellas County, Florida in accordance with Section 787.06(14) of the Florida Statutes. The affidavit must be completed and notarized by an authorized representative of any contractor bidding on Pinellas County contracts, specifically relating to the Notice of Intent to Sole Source for Uninterrupted Power Supply Battery Maintenance and Replacement Services (Contract No. 26-0024-N). The form attests that the contractor does not use coercion for labor or services as defined in Florida law.
The affidavit requires the contractor's authorized representative to sign under penalties of perjury, provide their printed name, date, and Federal Work Authorization User Identification Number. The form must be notarized before a notary public who will certify the signatory's identity through either physical presence or online notarization. All required fields include the contractor name, Pinellas County contract name and contract number, and the notary public's commission expiration date. This document serves as a mandatory compliance requirement for contractors seeking to do business with Pinellas County and must be submitted as part of the bid process through the OpenGov Procurement platform.
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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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