Human_Trafficking_Affidavit.docx
DOCX document 15 KB Posted
- Attached to
- Kitchen Renovations at Fire Station 4
- Solicitation number
- 2026-RFP-087
- Issued by
- Polk County, Florida
About this file
This is a Human Trafficking Affidavit form required by the City of Lakeland, Florida, for nongovernmental entities executing, renewing, or extending contracts with the municipality. The affidavit applies to the Kitchen Renovations Project at Fire Station 4 and must be completed and notarized by an authorized officer or representative of the contractor. The form requires certification that the contractor and its subsidiaries or affiliates do not use coercion for labor or services as defined under Section 787.06 of the Florida Statutes. Contractors must affirm under penalty of perjury that they will immediately notify the City of Lakeland if any future coercion for labor occurs, and acknowledge that failure to comply will prevent contract execution, renewal, or extension.
The affidavit must be notarized with either physical presence or online notarization before submission. The document requires the contractor to provide company name, authorized signature, printed name of the signatory, title, date, and notary information including the notary's signature, stamp or seal, printed name, and commission expiration date. This compliance document is a mandatory submission requirement for all proposals in response to the Kitchen Renovations at Fire Station 4 contract opportunity and must be included alongside other required documents such as project specifications, construction documents, indemnification forms, and PSM contractor audit forms.
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Text version
HUMAN TRAFFICKING AFFIDAVIT
In compliance with Section 787.06(14), Florida Statutes, this Affidavit must be completed by an officer or representative of a nongovernmental entity that is executing, renewing, or extending a contract with the City of Lakeland, Florida (the “Governmental Entity”).
The undersigned, on behalf of the entity listed below (the “Nongovernmental Entity”), hereby attests under penalty of perjury as follows:
1. I am over the age of 18 and I have personal knowledge of the matters set forth herein.
2. I am an officer or representative of_________________________, a Nongovernmental entity and I am authorized to provide this affidavit on behalf of Nongovernmental Entity.
3. Nongovernmental Entity, and any of its subsidiaries or affiliates, do not use coercion for labor or services, as those terms are defined in Section 787.06, Florida Statutes, as may be amended from time to time.
4. If, at any time in the future, Nongovernmental Entity does use coercion for labor or services, Nongovernmental Entity will immediately notify Governmental Entity and no contracts may be executed, renewed, or extended between the parties.
5. I have read the foregoing affidavit and confirm that the facts stated in it are true, and are made for the benefit of, and reliance by Governmental Entity.
Company: _______________________________________________ Authorized Signature: _____________________________________ Printed Name:____________________________________________ Date:______________________ Title: ____________________________________________________
STATE OF _________________
COUNTY OF _______________
The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this ____ day of ________________, 20____, by _________________________________, as _________________________ on behalf of the company/corporation. They ☐ are personally known to me or ☐ have produced _________________ as identification.
Notary Public Signature (Affix Notary Stamp or Seal) Print, Type or Stamp Name of Notary:__________ My commission expires:______________________
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