HomeMy WebLinkAboutAffidavits FR/SRATTACHMENT 1
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; MIAMI-DADE CRIMINAL RECORD AFFIDAVIT;
DISABILITY NONDISCRIMINATION AFFIDAVIT; and the PROJECT FRESH START AFFIDAVIT 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 LEASE"
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 and initial to the left of the statement, if applicable; or "N/A" if not
applicable; and/or provide the information requested.
I, , being first duly sworn state:
•Affiant
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 ID1 59-6000375
Federal Employer Identification Number (If none, Social Security)
City of Miami
Name of Entity, Individual(s), Partners, or Corporation
Doing Business As (if same as above, leave blank)
444 S.W. 2nd Avenue Miami, Florida 33130
Street Address City State Zip Code
1......MIAM1-DADE COUNTY Y OWNERSHIP DISCLOSU All-IDAViT (Sec:'2,8. 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 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):
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Full Legal Name
Address Ownership
OA
2. The full legal names 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 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
($500.00) or imprisonment in the County jail for up to sixty (60) days or both.
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 municipality of this State.
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:
White: Males Females Asian: Males Females
Black: Males Females American Indian: Males Females
Hispanics: Males Females Aleut (Eskimo): Males Females
..... . Dales Females
- Males. Females:
III. AFFIRMATIVE ACTION/NONDISCRIMINATION OF EMPLOYMENT, PROMOTION AND
PROCUREMENT PRACTICES (County Ordinance 98-30 codified at 2-8.1.5 of the County Code.)
In accordance with County Ordinance No. 98-30, entities with annual gross revenues in excess of
$5,000,000 seeking to contract with the County shall, as a condition of receiving a County contract,
have: i) a written affirmative action plan which sets forth the procedures the entity utilizes to assure that
it does not discriminate in its employment and promotion practices; and ii) a written procurement policy
which sets forth the procedures the entity utilizes to assure that it does not discriminate against minority
and women -owned businesses in its own procurement of goods, supplies and services. Such affirmative
action plans and procurement policies shall provide for periodic review to determine their effectiveness
in assuring the entity does not discriminate in its employment, promotion and procurement practices.
The foregoing notwithstanding, corporate entities whose boards of directors are representative of the
population make-up of the nation shall be presumed to have non-discriminatory employment and
procurement policies, and shall not be required to have written affirmative action plans and procurement
policies in order to receive a County contract. The foregoing presumption may be rebutted.
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The requirements of County Ordinance No. 98-30 may be waived upon the written recommendation of
the County Manager that it is in the best interest of the County to do so and upon approval of the Board
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 $5,000,000; however, its Board of Directors is
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 the
County's Department of Business Development, 175 N.W, 1st Avenue, 28th Floor, Miami,
Florida 33128.
The firm has annual gross revenues in excess of $5,000,000 and the firm does have a written
affirmative action plan and procurement'policy as described above, which includes periodic
reviews to determine effectiveness, fed has submitted the plan and policy to the Counters `
Department of Business Development 175 N.W. la' Avenue, 28th Floor, Miami, Florida
33128;
The firm does not have an affirmative action plan and/or a procurement policy as described
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.
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.
V. 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
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 -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 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.
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_VI. MIAMI-DADE 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 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 serious health
condition without risk of termination of employment or employer retaliation.
The foregoing requirements shall nor -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.
VII. DISABILITY NON-DISCRIMINATION 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 Accommodations 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, the State or any political
subdivision or agency thereof or any municipality of this State.
VIII. MIAMI-DARE 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,
organization or individual desiring to transact business or enter into a contract with the County
verifies that all delinquent and currently due fees or taxes -- including but not limited to real and
.propertytaxes, utility taxes and .occupational licenses..-- which are collected in the _normal course. by .
the Dade County Tax Collector as well as Dade County issued parking tickets for vehicles registered
in the name of the firm, corporation, organization or individual have been paid.
IX. CURRENT ON ALL COUNTY CONTRACTS, LOANS AND OTHER OBLIGATIONS
The individual entity seeking to transact business with the County is current in all its obligations to
the County and is not otherwise in default of any contract, promissory note or other loan document
with the County or any of its agencies or instrumentalities.
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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 shall
contribute to Project Fresh Start, the County's Welfare to Work Initiative. However, if five percent
(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 a
result of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, the firm may
request waiver from the requirements of R-702-98 and R-358-99 by submitting a waiver request
affidavit. The foregoing requirement does not pertain to government entities, not for profit
organizations or recipients of grant awards.
XI. DOMESTIC VIOLENCE LEAVE (Resolution 185-00; 99-5 Codified At 11A-60 Et. Seq. of the
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 11A-60 et. seq. of the Miami Dade County Code, which requires an
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" and
have indicated by an "X" all affidavits that pertain to this contract and have indicated by an "NIA" all affidavits
that do not pertain to this contract.
By:
(Signature of Affiant) (Date)
SUBSCRIBED AND SWORN TO (or affirmed) before me this day of
200 by He/She is personally
known to me or has presented as identification.
(Type of Identification)
(S ignature of Notary)
(Print or Stamp of Notary) (Expiration Date)
Notary Public — Stamp State of Notary Seal
(State)
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