HomeMy WebLinkAboutexhibit1DbATTACHMENT D
ATTACHMENT D
DEPARTMENT OF HUMAN SERVICES
BYRNE GRANT ADMINISTRATION
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 "NIA" all affidavits that do not pertain to this contract. All
blank spaces must be filled.
The MLAMI-DADS COUNTY OWNERSHIP
MDISCLOSURE
IAM DADS CRIMINAL ; RECORD�AFFIDE AV T;
Y
EMPLOYMENT DISCLOSURE
DISABILITY NONDISCRIMINATION United StatesIDr 'any of �sthe
departmcnts or agenlci s theeoF�heIISAate or any
VIT shall
not pertainal tod contractsorwith the of
political subdivision or agency there���cany i h heiUni municipality
States or any f its departmAepE nts or �enc es orILY the
VE
AFFIDAVIT shallr not y pertainoiticto co
State of Florida . any htical subdivisionttit enor tities nd it
carefully each affidavit totties of the
determine
State of Florida. All other contracting
whether or not it pertains to this contract.
I,
Affiant
The full legal n ame a nd b usiness a ddress o f the p erson(s) o r e ntity c ontracting o r t ransacting b usiness with
Miami -Dade County are (Post Office addresses are not acceptable):
being first duly sworn state:
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
-- L MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT (Sec. 2-8.1 of the County Code)
ness address
1. shall
the r business officertion andts with a di director and each stockholderoration, the full l legal
holds directly tor indirectly
shall be provided for each off's stock. If he contract or business
five percent t or more of the cinformation be providedtfor each partner. If the contractoor business
n is with a
partnership, thee foregoing inform
transaction is with a trust, the full legal
gmc and shall addressotpertainb to providedfor
r with publicly traded
d each
beneficiary. The foregoing , requirements
corporationsyca s to contracts with
a thereofUnited orates or any any municipality of this Startment or ate. thereof,
and
any political subdivision or agency
addresses are (Post Office addresses are not acceptable):
Full Legal Name Address
1 of 5
Ownership
2. The full legal names and business address of any other individual (other than subcontract
uita
beneficial
men, suppliers,
' in the contractor rior business tranwho sact or onlwith Dade County ave, any interest are (Post Off
beneficial or otherwise)
addresses are not acceptable):
3, Any p erson who w ill fully fails t o d inclose t he i nforrnation r equired h erein, o r w ho knowin
discloses false information in this regard, shall be punished bya fine
i es of
p to five hundred doll
($500.00) or imprisonment in the County jail for up to sixty (60) days
II. MIAMI-DADE COUNTY EMPLOYMENT
MPLSubsecOY (d) 2) DISCLOSURE the od AFFIDAVIT (County Ordinance No. 9(
133, Amending sec. 2.8-1;
Except where precluded by federal or State laws or regulations, each contractor
or essetran oi acti
renewal thereof which involves the expenditure
toof
ten disclose thedfolllowingS0} lnformation. The foregt
cr
the entity contracting or transacting usin
t
contracts with the United
es or any
ent
thereof,
of, Staeor arequirements do
tical subdivision or agency thereof or any municipality of this Stater age
thereof, the State or any p
1. Does your firm have a collective bargaining agreement with its employees?
Yes No
2 Does your firm provide paid health care benefits for its employees?
— Yes No
—
3. Provide a current breakdown (number of persons) of your firm's
work force and ownership as to race, national origin and gender:
Males Females
White: Males J Females Asian: Males Female:
Black: Males Females American Indian: — Males Female:
Hispanics: Males Females Aleut (Eskimo): Males Female:
• Males Females:
III. AFFIRMATIVE ACTION/NONDISCRIMINATION OF EMPLOYMENT, the County PROMOTION1
PROCUREMENT PRACTICES (County Ordinance 98-30 codified at
In accordance with County
Ordinance No, 98-30, entities with annual gross revenues in exec
con
have:
i) a writs king to contract Vactione the plan which sets forth the procedures the entity unty shall, as a condition of utilizes to County sure
hado: i) a written affirm a written
it does not discriminate inures temployment
e a titytut andpromotion
to assure that it does not discriminate against mil
rocurement c
which sets forth the prose and services. Such afftrn
and women -owned businesses in its own procurement of goods, supplies
action plans and procurement policies shall at
provide s employment, promotion on and riodic review to procurement prat
in assuring the entity does not discrimin
e The . foregoing notwithstanding, corporate entities whose boards of directors are
representative
reprsen tiv
pmake-up of thtberequired presumedbe anon-discriminatoryte oocen
procurement policies, and shall noto havewrittnaffrmatie action and procurresumption may be rebutted,
policies in order to receive a County contract. The foregoing p
2 of 5
The requirements of County Ordinance No. 98-30 may be waived upon the written recommendation
the County Manager that it is in the best interest of the County to do so and upon approval of the Bo;
of County Commissioners by majority vote of the members present.
The firm does not have annual gross revenues in excess of $5,000,000.
The firm does have annual revenues in excess of S5,000,000; however, its Board of Director:
representative of the population make-up of the nation and has submitted a written, detailed
listing of its Board of Directors, including the race or ethnicity of each board member, to
County's Department of Business Development, 175 N.W, 1st Avenue, 28th Floor, Mia
Florida 33128.
The firm has annual gross revenues in excess of $5,000,000 and the firm does have a writ
affirmative action plan and procurement policy as described above, which includes perk
e Coun
Department of BusinesscDe Development hassubmitted
N W s' Avehe nue, 28thFloor,Mito ami, Floi
Depart
33128;
The firm d oes n of have a n a fftrmative a ction plan a nd/or a procurement p obey a s d escri
above, but has been granted a waiver.
IV. MIAMI-DADE 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.
ing funding from
An officer, director, or hasexecutive of the not as of the dateofthis affidavit been convicted of aty entering into a contract or v
County has felony duringthe
ten (10) years.
V. MIAMI-DADE EMPLOYMENT DRUG-FREE
County WORKPLACE AFFIDAVIT (County Ordinance 1
92-15 codified as Section
ade County,
rida,
e al
That in compliance with Oproovidinnance No. 92-15 of a drug -free the Code of workplace. Aawrrtten statement ttooeach empi
named person or entity isproviding
shall inform the employee about:
1. danger of drug abuse in the workplace
2. the firm's policy of maintaining a drug -free environment at all workplaces
3picounseling, rehabilitationemployeeprograms
4. penalties that ofdrugemployees for drug abuse violatios
ee to
a statement, as a condition of
The person or entity shall also require
terms nd notify the sign employer of any criminal drug convi
loy
that the employee will abide by
occurring no later than five (5) days after receiving notice of such conviction and impose approl
personnel action against the employee up to and including termination.
Compliance with Ordinance No. 92-15 may be waived if the special characteristics of the prunty odi
i
service offered by the person or entity make it necessarfor t the
opeation of thects Coolving fu
fi
health, safety, welfare, economic benefits and well-being public.
which is provided in whole or in part by the United States or the State of Florida shall be exec
from the provisions of this ordinance in those instances where those provisions are in conflict wi
requirements of those governmental entities.
3 of 5
VI. MIAMI-DADE EMPLOYMENT FAMILY of the LEAVECoAFFntyIDdAVIT (County Ordinance No.
142-91 codified as Section 11 A et. seq
e
That in compliance with Ordinanc
e N� • 14ees2-91 of working hn Dade Coe Code ofunty foreachh working day ida, an
during
employer with fifty )50) or more pl y
each of twenty (20) or more calendar work weeks, 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
cluld(s4o se omontr other close relativelwho has,for the birth or
a serious health
adoption of a child, or for the care of P
condition without risk of termination of employment or employer retaliation.
d
tates or
The foregoing requirements shall not pertain
aor anyopa contracts
subdivision e orSagency thereof. department t shall,
agency thereof, or the State of Florida
however, pertain to municipalities of this State.
VII. DISABILITY NON-DISCRIMINATION AFFIDAVIT (County Resolution R-385-95)
iance with and
ees to continue
That the aboveh named firm corporateon or subcontractor, or third party coanization is in ntractor under this project complies
to comply with, and assure that any with all applicable requirements of the laws listed below including, but not limited to, those provisions pertaining to employment, provision of programs and services, transportation,
communications, access to facilities, renovations,s,P1b
and new L.
construction
ruction in
the
following
laws:
:U.S.C.e
Americans with Disabilities Act of 1990 (io), to meat; Title II, Public
12101-12213 and 47 U.S.G. Sections 225 and 611 includingTitle dI bEy Employment;
Entities; Title is
Services; Title III, Public Accommodations and Services OP
Telecommunications; and Title V, Miscellaneous Provisions;
The Rehabilitation Act of 1973, 29
The Fair Housing
U.S.C. Section 794; The Federal Transit Act, as amended 49 U.S.C. Sectiont1612;
shall not to
Act as amended, 42 U.S.C. Section 3601-3631. The foregoing q pertain
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.
VIII. MIAMI-DADE COUNTY REGARDING
DELINQUENT AND CURRENTLY DUE FEES OR
TAXES (Sec. 2-8.1(c) of the County Code)
Except for small purchase orders and sole source contracts,
that above named firm, corporation,
ntract with
County
organization or individual desiring no transact business or ly d rue f ees o r t axes - - enter ncl ding b ruin ot 1 imited t the r eaa b
verifies that all delinquent and currently
property taxes, utility taxes and occupational licenses -- which are collectedtickets for vehicles normal
registered courseby
the Dade County Tax Collector as well as Dade County issued parking
in the name of the firm, corporation, organization or individual have been paid.
IX. CURRENT ON ALL COUNTY CONTRACTS, LOANS AND OTHER OBLIGATIONS ations to
The individual entity seeking to transact business with the Couunnty isSQL rnr et in
otherallitsloan
ii document
the County and is not otherwise in default of any contract, p
with the County or any of its agencies or instrumentalities.
4 of 5
X. PROJECT FRESH START (Resolutions R-702-98 and 358-99)
Any firm that has a contract with the County that results in actual payment of $500,000 or more shal'
contribute to Project Fresh Start, the County's Welfare to Work Initiative. However, if five percen
(5%) of the firm's work force consists of individuals who reside in Miami -Dade County and who have
lost or will lose cash assistance benefits (formerly Aid to Families with Dependent Children) as r
result of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, the firm mat
request waiver from the requirements of R-702-98 and R-358-99 by submitting a waiver reques
affidavit. The foregoing requirement does not pertain to government entities, not for profi
organizations or recipients of grant awards.
XI. DOMESTIC VIOLENCE LEAVE (Resolution 185-00; 99-5 Codified At 11A-60 Et. Seq. of th(
Miami -Dade County Code).
The firm desiring to do business with the County is in compliance with Domestic Leave Ordinance.
Ordinance 99.5, codified at I 1A-60 et. seq. of the Miami Dade County Code, which requires ar
employer which has in the regular course of business fifty (50) or more employees working in Miami -
Dade County for each working day during each of twenty (20) or more calendar work weeks in the
current or proceeding calendar years, to provide Domestic Violence Leave to its employees.
I have carefully read this entire five (5) page document entitled, "Miami -Dade County Affidavits" any
have indicated by an "X" all affidavits that pertain to this contract and have indicated by an "N/A" all affidavit
that do not pertain to this contract.
By:
(Signature of Affiant)
SUBSCRIBED AND SWORN TO (or affirmed) before me this day of
(Date)
200_ by
He/She is personally
known to me or has presented
as identification.
(Type of Identification)
(Signature of Notary)
(Print or Stamp of Notary)
Notary Public — Stamp State of
(State)
(Serial Number)
(Expiration Date)
Notary Seal
5 of 5