Human_Trafficking_Affidavit_11.20.25.pdf
PDF 115 KB Posted
- Attached to
- Regen X Sweeper and Mechanical Lease
- Solicitation number
- 26-0581-ITB
- Issued by
- Pinellas County, Florida
About this file
This is a Human Trafficking Affidavit form required by Pinellas County, Florida, for the Regen X Sweeper and Mechanical Lease contract opportunity related to street sweeping program management. The affidavit serves as a certification document that must be completed and notarized by an authorized representative of the bidding contractor. The form requires the contractor to attest under penalties of perjury that it does not use coercion for labor or services as defined in Section 787.06 of the Florida Statutes, thereby confirming compliance with state human trafficking laws and regulations applicable to public contracting.
The affidavit must be signed by an authorized contractor representative, include printed name and date, and contain the Federal Work Authorization User Identification Number and the name and number of the Pinellas County Contract. The document requires notarization either through physical presence or online notarization, with the notary public providing their name, commission expiration date, and official seal. All contractor and notary information fields must be completed for the affidavit to be considered valid and acceptable for contract submission purposes.
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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 .