Human_Trafficking_Affidavit.pdf
PDF 89 KB Posted
- Solicitation number
- 26-0792-RFQ-CCNA
- Issued by
- Pinellas County, Florida
About this file
This is a Human Trafficking Affidavit form required by Pinellas County, Florida, in accordance with Section 787.06(13) of the Florida Statutes for the Gulf Beach Water Booster Station Improvements - Construction Management, Engineering, and Inspection Services project (PID 002150A). The affidavit requires an authorized representative of the contractor to attest under penalties of perjury that the contractor does not use coercion for labor or services as defined in Florida law. The form must be executed by a person with authority to bind the contractor and notarized before a notary public, with the notarization performed either through physical presence or online notarization.
The completed affidavit requires the contractor's authorized representative to provide their signature, printed name, date, and Federal Work Authorization User Identification Number, along with the name and number of the Pinellas County contract. The notary must acknowledge the instrument before them and provide their own notarization information, including their commission expiration date and the type of identification presented by the affiant. This form serves as a mandatory compliance document for contractors bidding on or executing county contracts in Florida and must be submitted as part of the contracting process.
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Text version
HUMAN TRAFFICKING AFFIDAVIT
In accordance with section 787.06 (13), 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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