HomeMy WebLinkAboutexhibit5MIAMI-DADE COUNTY DEPARTMENT OF CULTURAL AFFAIRS
UNIVERSAL AFFIDAVIT
Each section of this form must be read, and initialed indicating acceptance and/or compliance with the County's policy related to the particular affidavit.
For affidavit sections that you do not believe are applicable to your organization, please indicate this by placing "N/A" in the blank and your initials next
to the "N/A." ALL SECTIONS MUST BE COMPLETED, either with your initials indicating compliance or "N/A" indicating non -applicable. Sections not
completed on the Affidavit will render the entire Universal Affidavit null and void and it will be returned to you for completion.
The MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT, MIAMI-DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT, MIAMI-
DADE COUNTY CRIMINAL RECORD AFFIDAVIT, and MIAMI-DADE COUNTY DISABILITY NONDISCRIMINATION AFFIDAVIT shall not pertain to
contracts with the United States or any departments or agencies thereof, the State of Florida or any political subdivision or agency thereof, or any
municipality of this State. The MIAMI-DADE COUNTY FAMILY LEAVE AFFIDAVIT shall not pertain to contracts with the United States or any of its
departments or agencies, the State of Florida or any political subdivision or agency thereof, it shall, however, pertain'to municipalities of the State of
Florida.
1 being first duly sworn state:
(Name of Affiant 1 Authorized Official)
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
Name of Entity, Individual(s), Partners, or Corporation
Street Address City State Zip Code
I. MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT (Sec. 2-8.1 of the County Code)
1. If the contract or business transaction is with a corporation, the full legal name and business address shall be provided tor 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 Stale of Florida 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
2. The full legal name and business address of any other individual (other than subcontractors, material men, suppliers, laborers,
or lenders) who have, or will have, any interest (legal, equitable, beneficial or otherwise) in the contract or business transaction
with Miami -Dade County are (Post Office addresses are not acceptable):
3. 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) or imprisonment in the County jailfor up to sixty (60) days
lrt
Universal Affidavits (9/2004) Page I of 4
II. 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 muhicipality of this State.
1 Does your firm have a collective bargaining agreement with your employees?
_^Yes _No
. Does your firm provide paid health care benefits for its employees?
Yes No
3. Provide current breakdown (number of persons) of your firm's work force and ownership as to race, national origin and gender.
White: Males Females
Black:. — Males Females
Hispanic: Males Females
Native American: Males Females
Asian: Males — Females
Aleut (Eskimo): Males _ Females
Males .Females
Ill. 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.
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 convict�ce a felony dunng pastJ113) years - —
IV. MIAMI-DADE COUNTY 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 named person or entity 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 firm's policy of maintaining a drug -tree 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 person or entity shall also require an employee to sign a statement, as a 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.
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 operation 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
provisions of this ordinance in those instances where those provisions are in conflict with the requirements of those governmental
entities.
V. MIAMI-DADE COUNTY EMPLOYMENT FAMILY LEAVE AFFIDAVIT (County Ordinance No. 142-91 codified as Section 11A-29
et. seq. of the County Code)
That in compliance with Ordinance No. 142-91 of the Code of Miami -Dade County, Florida, an employer with fifty (50) or more
employees working in Miami -Dade County for each working day during each twenty (20) or more calendar work weeks, shall provide the
following information in compliance with all items in the aforementioned ordinance:
Universal Affidavits (9/2004) Page 2 of 4
An employee who has worked for the above firm at feast 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 serious 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.
VI. MIAMI-DADE COUNTY DISABILITY NONDISCRIMINATION AFFIDAVIT (County Resolution R-385-95)
That the above named firm, corporation or organization is in compliance with and agrees to continue to comply with, and assure that
any subcontractor, or third party contractor under this project complies 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, and new construction in the following laws: The Americans with Disabilities Act of
1990 (ADA), Pub. L. 101.336, 104 Stat. 327, 42 U. S. C. 12101-12213 and 47 U. S. C. Sections 225 and 611 including Title I,
Employment; Title II, Public Services; Title III, Public Accommodation and Services Operated by Private Entities; Title IV,
Telecommunications; and Title V, Miscellaneous Provisions: The Rehabilitation Act of 1973, 29 U.S.C. Section 794: The Federal
Transit Act, as amended.49 U .S. C. Section 1612: The Fair Housing Act as amended, 42 U.S.C. Section 3601-3631. The foregoing
requirements shall not pertain to contracts with the United States or any department or agency thereof, or the State or any political
subdivision or agency thereof or any municipality of this State.
VII. MIAMI-DADE COUNTY AFFIDAVIT 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, the above named firm, corporation, organization or individual desiring to
transact business or enter into a contract with the County verifies that all delinquent and currently due lees or'taxes -- including but not
limited to real and property taxes, utility taxes and occupational licenses -- which are collected in the normal course by the Miami -Dade
County Tax Collector as well as Miami -Dade County issued parking tickets for vehicles registered in the,name of the firm, corporation,
organization or individual have been paid.
VIII. MIAMI-DADE COUNTY WELFARE REFORM WORK PARTICIPATION AFFIDAVIT (Resolution R-702-98, as amended by
Resolution R-358-99).
Please check one of the following options:
This entity is a governmental entity and is therefore exempt from the provisions of Resolution No. R-702-98, as
amended by Resolution R•358-99.
This entity is a not -for -profit organization and is therefore exempt from the provisions of Resolution No. R-702-
98, as amended by Resolution R-358-99.
This entity is a recipient of a grant award and is therefore exempt from the provisions of Resolution No. R-702-
98, as amended by Resolution R-358-99.
This entity has a contract with the County that results in actual payment of less than $500,000 and is therefore
exempt from the provisions of Resolution No. R-702-98.
This entity can demonstrate that five percent,(5%) of its work force consists of individuals who reside in Miami -
Dade County and who have lost or who will lose cash assistance benefits (formerly Aid to Families with
Dependent Children or 'AFDC') as a result of the Personal Responsibility and Work Opportunity Reconciliation
Act of 1996, and therefore, requests a waiver of the requirements of Resolution No. R-702-98, as amended by
Resolution R-358-99.
This entity has a contract with the County that results in actual payment of $500,000 or more, and therefore,
will contribute to Project Fresh Start, the County's welfare -to -work initiative, based on the following scale:
If the entity has a contract with the County that results in actual payment of an amount between:
$500,000 to $1,000,000
$1,000,001 to $5,000,000
$5,000,001 to $10,000,000
$10,000,001 and over
then that entity shall contribute $5,000
then that entity shall contribute $10,000
then that entity shall contribute $20,000
then that entity shall contribute $25,000
I Ir,,r+rcal Affidavits 19/20041
Page 3 of 4
4
I have carefully read this entire four (4) page document entitled, "Universal Affidavit" and have initialed ail affidavits that pertain to this contract ana
have indicated by "NA" all affidavits that do not pertain to this contract.
By:
(Signature of ANiant) (Date)
SUBSCRIBED AND SWORN TO (or affirmed) before me this _ day of , 20 by
He / She:
❑ is personally known to me — or —
❑ has produced as identification.
(Type of Identification)
, Notary Public
(Signature of Notary)
(Name of Notary Typed,.P._rinted or..Stamped) _... .
State of Florida - County of Imprint of Notary Seal
Universal Affidavits (912004) Page 4 of 4