Human_Trafficking_Affidavit_-FOR_EXAMPLE_ONLY.pdf
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- Solicitation number
- 26-0494-RFQ-CCNAC
- Issued by
- Pinellas County, Florida
About this file
This is a Human Trafficking Affidavit form required by Pinellas County, Florida in compliance with Section 787.06 of the Florida Statutes. The affidavit serves as a certification document for contractors bidding on county contracts, specifically within the context of professional engineering services procurements governed by the Consultants' Competitive Negotiation Act (CCNA). The form 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 document must be notarized, with the notary public certifying the contractor representative's identity and the date of acknowledgment, whether executed through physical presence or online notarization.
The affidavit includes spaces for the contractor's name, the authorized representative's signature and printed name, Federal Work Authorization User Identification Number, the specific Pinellas County contract name and number, and the notary's information including commission expiration date. This certification is a mandatory compliance requirement for contractors seeking to engage with Pinellas County on professional services contracts, ensuring adherence to state human trafficking statutes and labor law provisions as a condition of contract eligibility.
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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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