Human_Trafficking_Affidavit_11.20.25.pdf
PDF 115 KB Posted
- Solicitation number
- 26-0600-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, for the Behavioral Health Coordinated Access Model (CAM) contract opportunity. The affidavit serves as a mandatory attestation that the contractor does not use coercion for labor or services as defined under Florida law. The document requires an authorized representative of the contracting organization to execute the affidavit under penalties of perjury, declaring that the facts stated are true. The form includes fields for the contractor's authorized representative signature, printed name, date, Federal Work Authorization User Identification Number, and the name and number of the Pinellas County contract.
The affidavit must be notarized before a Florida notary public, with the notary documenting whether acknowledgment occurred through physical presence or online notarization. The form requires the notary to provide their seal, printed name, commission expiration date, and identification method used to verify the affiant's identity. This certification is a compliance requirement for all contractors bidding on the Pinellas County Coordinated Access Model contract and must be submitted as part of the proposal package. The affidavit ensures that selected vendors meet state statutory requirements regarding human trafficking prevention and labor practice standards prior to contract award.
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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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