HomeMy WebLinkAboutExhibit 2ATTACHMENT B
MIAMI DADE COUNTY AFFIDAVITS
MIAMI
HOUSING AGENCY
DOCUMENT 00999-4
B. MIAMI DADE COUNTY AFFIDAVITS
I. MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT
2. MIAMI-DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT
3. MIAMI-DADE COUNTY CRIMINAL RECORD AFFIDAVIT
4. MIAMI-DADE LMPLOYNTENT DRUG FREE WORKPLACE
AFFIDAVIT
5. MIAMI-DADE EMPLOYMENT FAMILY LEAVE AFFIDAVIT
6. PUBLIC ENTITY CRIMES AFFIDAVIT
7. FORM OF NON -COLLUSIVE AFFIDAVIT
S. MIAMI-DADE COUNTY COLLECTION OF TAXES, FEES AND
PARKING TICKETS AFFIDAVIT
9. AFFIDAVIT RELATING TO INDIVIDUALS AND ENTITIES
ATTESTING BEING CURRENT IN THEIR OBLIGATIONS TO
MIAMI-DADE COUNTY
MIAMI-DADE COUNTY AFFIDAVITS
The contracting individual or entity (governmental or otherwise) shall indicate by an "X" all affidavits that pertain to
this contract and shall indicate by an "N/A" all affidavits that do not pertain to this contract. All blank spaces must
be filled.
The MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT; MIAMI-DADE COUNTY
EMPLOYMENT DISCLOSURE AFFIDAVIT; and the MIAMI-DADE CRIMINAL RECORD AFFIDAVIT; and
the shall not pertain to contracts with the United States or any of its departments or agencies thereof, the State or any
political subdivision or agency thereof or any municipality of this State. The MIAMI-DADE FAMILY LEAVE
AFFIDAVIT shall not pertain to contracts with the United States or any of its departments or agencies or the State
of Florida or any political subdivision or agency thereof; it shall, however, pertain to municipalities of the State of
Florida. All other contracting entities or individuals shall read carefully each affidavit to determine whether or not it
pertains to this contract.
being first duly sworn state:
The full legal name and business address of the person(s) or entity contracting or transacting business with Miami -
Dade County are (Post Office addresses are not acceptable):
Federal Employer Identification Number (If none, Social Security)
Name of Entity, Individual(s), Partners, or Corporation
Doing Business As (If same as above, leave blank)
Street Address City State Zip Code
1. MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT (Sec. 2-8.1 of the
County Code)
A. If the contract or business transaction is with a corporation, the full legal name and business
address shall be provided for each officer and director and each stockholder who holds directly or
indirectly five percent (5%) or more of the corporation's stock. If the contract or business
transaction is with a partnership, the foregoing information shall be provided for each partner. If
the contract or business transaction is with a trust, the full legal name and address shall be
provided for each trustee and each beneficiary. The foregoing requirements shall not pertain to
contracts with publicly -traded corporations or to contracts with the United States or any
department or agency thereof, the State or any political subdivision or agency thereof or any
municipality of this State. All such names and addresses . are (Post Office addresses are not
acceptable):
Full Legal Name Address Ownership
°/O
3.
4.
B. The full names and business address of any other individual (other than subcontractors,
materialmen, suppliers laborers or lenders) who have, or will have any interest (legal, equitable
beneficial or otherwise) in the contract or business transaction with Dade County are (Post Office
addresses are not acceptable):
C. Any person who willfully fails to disclose the information required herein, or who knowingly
discloses false information in this regard, shall be punished by a fine of up to five hundred dollars
($500.00) or imprisonment in the County jail for up to sixty (60) days or both.
MIAMI-DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT (County
Ordinance No. 90-133, Amending sec. 2.8-1; Subsection (d)(2) of the County Code).
Except where precluded by federal or State laws or regulations, each contract or business transaction or
renewal thereof which involves the expenditure of ten thousand dollars ($10,000) or more shall require the
entity contracting or transacting business to disclose the following information. The foregoing disclosure
requirements do not apply to contracts with the United States or any department or agency thereof, the
State or any political subdivision or agency thereof or any municipality of this State.
A. Does your firm have a collective bargaining agreement with its employees?
Yes No
B. Does your firm provide paid health care benefits for its employees?
Yes No
C. Provide a current breakdown (number of persons) of your firm's work force and ownership as to
race, national origin and gender:
White: Males Females Asian: Males Females:
Black: Males Females American Indian: Males Females
Hispanics: Males Females Aleut (Eskimo): Males Females
MIAMI -DADS COUNTY CRIMINAL RECORD AFFIDAVIT (Section 2-8.6 of the County
Code)
The individual or entity entering into a contract or receiving funding from the County has
has not as of the date of this affidavit been convicted of a felony during the past ten (10) years.
An officer, director, or executive of the entity entering into a contract or receiving funding from the County
has has not as of the date of this affidavit been convicted of a felony during the past ten (10)
years.
MIAMI-DADE EMPLOYMENT DRUG FREE WORKPLACE AFFIDAVIT (County
Ordinance No. 92-15 codified as Section 2-8.1.2 of the County Code)
That in compliance with Ordinance No. 92-15 of the Code of Miami -Dade County, Florida, the above
names person or entity is providing a drug-free workplace. A written statement to each employee shall
inform the employees about:
A. danger of drug abuse in the workplace
B. the firm's policy of maintaining a drug-free environment at all workplaces
C. availability of drug counseling, rehabilitation and employee assistance programs
D. penalties that me be imposes upon each employees for drug abuse violations
That the person or entity shall also require an employee to sign a statement, as condition of employment
that the employee will abide by the terms and notify the employer of any criminal drug conviction
occurring no later than five (5) days after receiving notice of such conviction and impose appropriate
personnel action against the employee up to and including termination of employment or employer
retaliation.
Compliance with Ordinance No. 92-15 may be waived if the special characteristics of the product or
service offered by the person or entity make it necessary for the operations of the County or for the health,
safety, welfare, economic benefits and well being of the public. Contracts involving funding which is
provided in whole or in part by the United States or the State of Florida shall be exempted from the
provision of this Ordinance in those instances where those provisions are in conflict with the requirements
of those governmental entities.
5. MIAMI -DADS EMPLOYMENT FAMILY LEAVE AFFIDAVIT (County Ordinance No.
142-9) codified as Section IIA -29 et. seq of the County Code)
That in compliance with Ordinance No. 149-91 of the Code of Miami -Dade County, Florida, an employer
with fifty (50) or more employees working in Dade County for each working day during each of twenty
(20) or more calendar work weeks, shall provide the following information in compliance with all items in
the aforementioned ordinance
An employee who has worked for the above firm at least one (1) year shall be entitled to ninety (90) days
of family leave during any twenty four (24) month period, for medical reasons, for the birth or adoption of
a child, or for the care of a child, spouse or other close relative who has a serous health condition without
risk of termination of employment or employer retaliation.
The foregoing requirements shall not pertain to contracts with the United States or any department or
agency thereof, or the State of Florida or any political subdivision or agency thereof. It shall, however,
pertain to municipalities of this State.
PUBLIC ENTITY CRIMES AFFIDAVIT
(SECTION 287.133(3)(a), FLORIDA STATUTES)
NOTE: THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
OFFICER AUTHORIZED TO ADMINISTER OATHS.
A. This sworn statement is submitted with Bid, Proposal, or Contract No. for
B. This sworn statement is submitted by
NAME OF ENTITY SUBMITTING SWORN STATEMENT
whose business address is
and (if applicable) its Federal Employer Identification
Number (FEIN) is If the entity has no FEIN, include the Social Security
number of the individual
signing this sworn statement:
C. My name is , and my relationship to the entity named
Print name of individual signing
above is
D. I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida
Statutes, means a violation of any state or federal law by a person with respect to and directly
related to the transaction of business with any public entity or with an agency or political
subdivision of any other state or with the United States, including, but not limited to any bid
or contract for goods or services to be provided to any public entity or an agency or political
subdivision of any other state or of the United States and involving antitrust, fraud, theft,
bribery, collusion, racketeering, conspiracy, or material misrepresentation.
E. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(l)(b), Florida
Statutes, means a finding of guilt or a conviction of a public entity crime, with or without an
adjudication of guilt, in any federal or state trial court of record relating to charges brought
by indictment or information after July 1, 1989, as a result of a jury verdict, non jury trial, or
entry of a plea of guilty or nolo contender.
F. I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes,
means:
(i) A predecessor or successor of a person convicted of a public entity crime: or
(ii) An entity under the control of any natural person who is active in the management of the
entity and who has been convicted of a public entity crime. The term "affiliate" includes
those officers, directors, executives, partners, shareholders, employees, members, and
agents who are active in the management of an affiliate. The ownership by one person of
shares constituting a controlling interest in another person, or a pooling of equipment or
income among persons when not for fair market value under an arm's length agreement,
shall be a prima facie case that one person control another person. A person who
knowingly enters into a joint venture with a person who has been convicted of a public
entity crime in Florida during the preceding 36 months shall be considered an affiliate.
G. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes means
any natural person or entity organized under the laws of any state or of the United States
with the legal power to enter into a binding contract and which bids or applies to bid on
contracts for the provision of goods or services let by a public entity, or which otherwise
transacts or applies to transact business with a public entity. The term "person" includes
those officers, directors, executives, partners, shareholders, employees, members, and agents
who are active in management of an entity.
H. Based on information and belief, the statement, which I have marked below, is true in
relation to the entity submitting this sworn statement. (Please indicates which statement
applies.)
(i) _ Neither the entity submitting this sworn statement, nor any officers, directors,
executives, partners, shareholders, employees, members, or agents who are active in
management of the entity, nor any affiliate of the entity have been charged with and
convicted of a public entity crime subsequent to July 1, 1989.
(ii) _ The entity submitting this sworn statement, or one or more of the officers, directors,
executives, partners, shareholders, employees, members, or agents who are active in
management of the entity, or an affiliate of the entity has been charged with and
convicted of a public entity crime subsequent to July 1, 1989, AND (please indicate
which additional statement applies.)
• There has been a proceeding concerning the conviction before a hearing officer of
the State of Florida, Division of Administrative Hearings. The final order entered
by the hearing officer did not place the person or affiliate on the convicted vendor
list. (Please attach a copy of the final order.)
• The person or affiliate was placed on the convicted vendor list. There has been a
subsequent proceeding before a hearing officer of the State of Florida, Division of
Administrative Hearings. The final order entered by the hearing officer
determined that it was in the public interest to remove the person or affiliate from
the convicted vendor list. (Please attach a copy of the final order.)
The person or affiliate has not been placed on the convicted vendor Iist. (Please
describe any action taken by or pending with the Department of General
Services.)
FORM OF NON -COLLUSIVE AFFIDAVIT
DEVELOPMENT NAME:
HUD DEVELOPMENT NO:
STATE OF )
) SS:
COUNTY OF )
Being first duly sworn, deposes and says:
That he is the party making the foregoing proposal
or bid, that said bidder has visited the site of the work and has carefully examined the plans and
specifications for said Project and checked them in detail before submitting his bid or proposal; and
further, that such proposal or bid is genuine and not collusive or sham; that said bidder has not colluded,
conspired, connived or agreed, directly or indirectly, with any bidder or person, to put in a sham bid or to
refrain from bidding, and has not in any manner, directly or indirectly, sought by agreement or collusion,
or communication or conference, with any person, to fix the bid price of affiant or of any other bidder, or
to fix any overhead, profit or cost element of said bid rice, or of that of any other bidder, or to secure any
advantage against Miami -Dade County, Florida, or any person interested in the proposed Contract; and
that all statements in said proposal or bid are true.
S. MIAMI -DARE COUNTY COLLECTION OF TAXES, FEES AND
PARKING TICKETS AFFIDAVIT (Ordinance 95-178)
I, being first duly sworn state that in compliance with the procedures contained in Section 2-8.1(c) of the Code of
Miami -Dade County, and as amended by Ordinance 95-178, this firm hereby certifies that the foregoing statements
are true and correct.
That all delinquent and currently due fees or taxes (including, but not limited to, real and personal property taxes,
convention and tourist development taxes, utility taxes, and occupational license taxes) collected in the normal
course by the Miami -Dade County Tax Collector and County issued parking tickets for vehicles registered in the
name of the above firm, have been paid.
9. AFFIDAVIT RELATING TO INDIVIDUALS AND ENTITIES
ATTESTING BEING CURRENT IN THEIR OBLIGATIONS TO MIAMI-
DADE. COUNTY (Ordinance 99-162)
1, being first duly sworn state that in compliance with County Ordinance 99-162, the bidder is not in arrears in any
payment under a contract, promissory note or other loan document with the County, or any of its agencies or
instrumentalities, including the Public Health Trust (hereinafter referred to as "County"), either directly or indirectly
through a firm, corporation, partnership or joint venture in which the individual or entity has a controlling financial
interest as that term is defined in Section 2-11.1(b)(8) of the County Code.
I have carefully read this entire six (6) page document entitled, "Miami- Dade County
Affidavits" (Affidavits 1-9) and have indicated by "X" all affidavits that pertain to this contract
and have indicated by an "N/A" all affidavits that do not pertain to this contract and completed
all required information
BY SIGNING AND NOTARIZING THIS PAGE YOU ARE ATTESTING TO
AFFIDAVITS ONE (1) THROUGH NINE (9)
MIAMI-DADE COUNTY AFFIDAVITS SIGNATURE PAGE
0
Signature of Witness or Secretary Seal
Signature of Affiant: Bidder, if the bidder is an
Individual; partner, if the Bidder is a Partnership;
Officer, if the Bidder is a Corporation
20
Date
Federal Employer Identification Number
Printed Name of Firm and Affiant
Address of Firm
SUBSCRIBED AND SWORN TO (or affirmed) before me this day of , 20
He/She is personally known to me or has presented as identification.
Type of identification
Signature of Notary
Print or Stamp Name of Notary
Notary Public — State of
Serial Number
Expiration Date
Notary Seal
Miami -Dade County
MIAM�UADE VENDOR AFFIDAvas FORM
(Uniform County Affidavits)
Department of Procurement Management
Vendor Assistance Unit
111 NW 1" Street, Suite 1300, Miami, Florida 33128-1974
Telephone: 305-375-5773 Fax No: 305-375-5409
www.miamidade.00v/dnm
Complete the Vendor Affidavits Form to update affidavits previously submitted with the
Vendor Registration Package. It is the vendor's responslbiiity, to keep all affidavit
information current complete and accurate, by submitting any modifications to the
Department of Procurement Management Vendor Assistance Unit.
FEDERAL EMPLQYER
IDENTIFICATION NUMBER (FEIN
In order to establish a File for your firm, you must
enter your firms FEIN or if none, the owner's Social
Security Number. This number becomes your "County
Vendor Number".
Please enter your Federal Employee Identification
Number (FEIN) or your Social Security Number
(SSN).
❑ F.E.I.N.
❑ S.S.N.
Name of Entity, Individual (s), Partners, or Corporation
Doing Business As (If same as above, leave blank)
Street Address (Post Office addresses are not acceptable)
1. MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT
(Sec. 2-8.1 of the Miami -Dade County Code)
a. Firms registered to do business with Miami -Dade County must fully disclose their legal name, physical address and ownership. Publicly
traded Corporations are exempt from this requirement, but must indicate by letter that it is a Publicly Traded Corporation and
include the name of the stock exchange market and symbol where registered.
If the contract or business transaction is with a corporation, the full legal name and business address shall be provided for each
officer and director and each stockholder who holds directly or Indirectly five percent (5%) or more of the corporation's stock. if the
contract or business transaction is with a trust, the full legal name and address shall be provided for each trustee and each
beneficiary. (Post Office addresses are not acceptable). (Duplicate page if needed for additional names).
If no officer, director or stockholder owns (5%) or more of stock, please write "None" below.
FULL LEGAL NAME TITLE ADDRESS % OF
OWNERSHIP
b. Provide the full legal names and business addresses of any other individuals (other than subcontractors, material men, suppliers,
laborers, or lenders) that have, or will have, any interest (legal, equitable beneficial or otherwise) in the contract or business
transaction with Miami Dade County (Post Office addresses are not acceptable). If "None", please indicate in space below:
FULL LEGAL NAME TITLE ADDRESS % OF
OWNERSHIP
4/23/2008
2. MIAMI -DADS COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT
(County Ordinance No. 90-133, amending Section 2.8-1(d)(2) of the Miami -Dade County Code)
The following information is for compliance with all items in the aforementioned Section:
1. Does your firm have a collecilve bargaining agreement with its
employees? Yes
2. Does your firm provide paid health care benefits for its employees?
Yes
No
No
3. Provide a current breakdown (number of persons) of your firm's work force and ownership as to race, national origin and gender:
White
Black Hispanic Other
Males
Males Males Males
Females
Females Females Females
My initiah acknowledge that 1 have read the aforementioned requirements and the entity is in compliance. F7
3. MIAN-DADS COUNTY EMPLOYMENT DRUG-FREE: WORKPLACE CERTIFICATION
(Section 2-8.1.2(b) of the Miami- Dade County Code)
All persons and entities that contract with Miami -Dade County are required to certify that they will maintain a drug-free workplace and such
persons and entities are required to provide notice to employees and to impose sanctions for drug violations occurring in the workplace.
In compliance with Ordinance No. 92-15 of the Code of Miami -Dade County, the above named firm is providing a drug-free workplace. A
written statement to each employee shall inform the employee about:
1. Danger of drug abuse in the workplace
2. The firms' policy of maintaining a drug-free environment at all workplaces
3. Availability of drug counseling, rehabilitation and employee assistance programs
4, Penalties that may be imposed upon employees for drug abuse violations
The firm shall also require an employee to sign a statement, as a condition of employment that the employee will abide by the terms of the drug-
free workplace policy and notify the employer of any criminal drug conviction occurring no later than five (5) days after receiving notice of such
conviction and impose appropriate personnel action against the employee up to and including termination. Firms may also comply with the
County's Drug Free Workplace Certification where a person or entity is required to have a drug-free workplace policy by another local, state or
federal agency, or maintains such a policy of its own accord and such policy meets the intent of this ordinance.
My initials acknowledge that I have read the aforementioned requirements anal the entity is in compliance, F7
MIAMi-DADE COUNTY DISABILITY AND NONDISCRIMINATION AFFIDAVIT
(Article 1, Section 2-8.1.5 Resolution R182-00 Amending R-385-95 of the Miami -Dade County Code)
Firms transacting business with Miami -Dade County shall provide an affidavit indicating compliance with all requirements of the Americans with
Disabilities Act (A.D.A.).
1, state that this firm, is in compliance with and agrees to continue to comply with, and assure that any subcontractor, or third party contractor shall
comply with all applicable requirements of the laws including, but not limited to, those provisions pertaining to employment, provision of programs
and services, transportation, communications, access to facilities, renovations, and new construction.
The American with Disabilities Act of 1990 (ADA), Pub. L. 101-336, 104 Stat 327, 42 U.S.C. Sections 225 and 611 including Titles I, II, Ili, IV and
V.
The Rehabilitation Act of 1973, 29 U.S.C. Section 794
The Federal Transit Act, as amended, 49 U.S.C. Section 1 612
The Fair Housing Act as amended, 42 U.S.C. Section 3601-3631
1. hereby affirm that 1 am in compliance with the below sections:
Section 2-10.4(4)(a) of the Code of Miami -Dade County (Ordinance No. 82-37), which requires that all properly licensed architectural,
engineering, landscape architectural, and land surveyors have an affirmative action plan on file with Miami -Dade County.
Section 2-8.1.5 of the Code of Miami -Dade County, which requires that firms that have annual gross revenues in excess of five (5) million dollars
have an affirmative action plan and procurement policy on file with Miami -Dade County. Firms that have a Board of Directors that are
representative of the population make-up of the nation may be exempt.
My initials acknowledge that t have read the aforementioned requirements and the entity is in compliance F7
4/23/200.
5. MIAMi-DADE COUNTY DEBARMENT DISCLOSURE AFFIDAVIT
(Section 10.38 of the Miami -Dade County Code)
Firms wishing to do business with Miami -Dade County must certify that its contractors, subcontractors, officers, principals, stockholders, or affiliates
are not debarred by the County before submitting a bid.
I, confirm that none of this firms agents, officers, principals, stockholders, subcontractors or their affiliates are debarred by Miami -Dade County.
My initials acknowledge that I have read the aforementioned requirements and the entity is in compliance. El
6. MIAMI-DADE COUNTY VENDOR OBLIGATION TO COUNTY AFFIDAVIT
(Section 2-8.1 of the Miami -Dade County Code)
Firms wishing to transact business with Miami -Dade County must certify that all delinquent and currently due fees, taxes and parking tickets have
been paid and no individual or entity in arrears in any payment under a contract, promissory note or other document with the County shall be
allowed to receive any new business.
1, confirm that all delinquent and currently due fees or taxes including, but not limited to, real and personal property taxes, convention and tourist
development taxes, utility taxes, and Local Business Tax Receipt collected in the normal course by the Miami -Dade County Tax Collector and
County issued parking tickets for vehicles registered in the name of the above firm, have been paid.
I further affirm that this firm complies with Section 2-8.1, which requires that no individual or entity that is in arrears in any payment under a
contract, promissory note or other document with the County shall be allowed to receive any new business.
My initials acknowledge that I have read the aforementioned requirements and the entity is in compliance.
7. MIAMi-DADE COUNTY CODE OF BUSINESS ETHICS AFFIDAVIT
(Article 1, Section 2-8.1(i) and 2-11(6)(1) of the Miami -Dade County Code through (6) and (9) of the County Code and County Ordinance No 00-1
amending Section 2-17.7 (c) of the County Code)
Firms wishing to transact business with Miami -Dade County must certify that it has adopted a Code that complies with the requirements of Section
2-8.1 of the County Code. The Code of Business Ethics shall apply to all business that the contractor does with the County and shall, at a minimum;
require the contractor to comply with all applicable governmental rules and regulations.
I confirm that this firm has adopted a Code of business ethics which complies with the requirements of Sections 2-8.1 of the County Code, and that
such code of business ethics shall apply to all business that this firm does with the County and shall, at a minimum, require the contractor to comply
with all applicable governmental rules and regulations.
My initials acknowledge that f have read the aforementioned requirements and the entity is in compliance F7
8. MIAMI-DADE COUNTY FAMILY LEAVE AFFIDAVIT
(Article V of Chapter 11, of the Miami -Dade County Code)
Firms contracting business with Miami -Dade County, which have more than fifty (50) employees for each working day during each of twenty (20)
or more work weeks in the current or preceding calendar year, are required to certify that they provide family leave to their employees.
Firms with less than the number of employees indicated above are exempt from this requirement, but must indicate by letter (signed by an
authorized agent) that it does not have the minimum number of employees required by the County Code,
I confirm that if applicable, this firm complies with Article V of Chapter 11 of the County Code, which requires that firms contracting business with
Miami -Dade County which have more than fifty (50) employees for each working day during each of twenty {20) or more work weeks in the
current or preceding calendar year are required to certify that they provide family leave to their employees.
My initials acknowledge that I have read the aforementioned requirements and the entity is in compliance. 7
9. MIAMI-DADE COUNTY LIVING WAGE AFFIDAVIT
(Section 2-8.9 of the Miami -Dade County Code)
All applicable contractors entering into a contract with the County shall agree to pay the prevailing living wage required by this section of the
County Code.
I confirm that if applicable, this firm complies with Section 2-8.9 of the County Code, which requires that all applicable employers entering a
contract with Miami -Dade County shall pay the prevailing living wage required by the section of the County Code.
My initials acknowledge that I have read the aforementioned requirements and the entity is in compliance.
4/23/Zaae
10. MIAMI-DADE COUNTY DOMESTIC LEAVE AND REPORTING AFFIDAVIT
(Article 8, Section 1 1 A-60 - 1 1 A-67 of the Miami -Dade County Code)
Firms wishing to transact business with Miami -Dade County must certify that it is in compliance with the Domestic Leave Ordinance,
I confirm that if applicable, this firm complies with the Domestic Leave Ordinance. This ordinance applies to employers that have, in the regular
course of business, fifty (50) or more employees working in Miami -Dade County for each working day during the current or preceding calendar
year.
My initials acknowledge that I have read the aforementioned requirements and the entity is in compliance, F7
AFFIRMATION
I, being duly sworn, do attest under penalty of perjury that the entity is in compliance with all requirements outlined in the Miami -Dade County
Vendor Affidavits 1 — 10, pages 5 through 8 of this Vendor Registration Package.
I also attest that I will comply with and keep current all statements sworn to in the above affidavits and registration application. I will notify the
Miami -Dade County, Vendor Assistance Unit, immediately if any of the statements attested hereto are no longer valid.
(Signature of Afflant)
Notary Public — State of:
State
Name of Affiant and
NOTARY PUBLIC iNFORMATfON
SUBSCRIBED AND SWORN TO (or affirmed) before me this day of
County of
m
by He or she is personally known to me ❑ Or has produced identification ❑
Type of Identification Produced
Signature of Notary Public (Serial Number)
Print or Stamp of Notary Public
4/23/2008 4
Expiration Date Notary Public Seal