HomeMy WebLinkAboutAttachment JATTACHMENT
MI A_MI-DARE COUNTY HOMELESS TRUST
t\TL.A_Ivll-DADE COUNTY Rr.QUIRED . FIDAVITS
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 MI: MI -DADS COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT; M1A\11-DADE COUNTY
EMPLOYMENT DISCLOSURE AFFIDAVIT; MIAMI-DADE CRIMINAL RECORD AFFIDAV[T;
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 FA1vtILY
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.
Affiant
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 Off cc 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
_I. MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE .AFFIDAVIT (Sec. 2-8.1 of the County Code)
I. 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 of agency thereof or any municipality of this State. All such names and
addresses are (Post Office addresses are not acceptable):
1of5
Full Legal Name
Address Ownership
00
0'
:0
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 (S500.00) 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
Does your firm provide paid health care benefits for its employees?
Yes No
3. Provide a current breakdown. (number of persons) of your firms
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•
Males Females: Males Females
_III. AFFIRMA 11 VE ACT 1ONfNONDISCRJMvfINATION 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
15,000,000 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 reviewto deter nine 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 maize -up of the nation shall he presumed to have non-discrinn oaro;,-
employment and procurement policies, and shall not be required to have written a in native
plans and procurement policies in order to receive 3 County contract. The foregoing presurnptron n—n.
be rebutted.
The requirements of County Ordinance No. 9S-30 may be waived upon the written recomrnerdation of
the Counry Manager that it is in the best interest of the Counry 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 S5,000,000.
The firm does have annual revenues in excess of S5,000,000; however, its Board of Directors is
representative of the population•make-up of the nation and has submitted a v.Titten, 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 33I28.
The firm has annual gross revenues in excess of S.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, and has submitted the plan and policy to the County's
Department of Business Development I75 N.W. 1st 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.
MIAMI-DADE EMPLOYMENT DRUG -FREE WORKPLACE AFFIDAVIT (County Ordinance No.
92-15 codified as Section 2,8.12 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 theprovisions of this ordinance in those instances where those provisions are in conflict with
the requirements of those novemmental entities.
_VI. KAivf1-DADS EhfPLOYMENT FAMILY LEAVE AFFIDAVIT (County Ordinance No
1.2-91 codified as Section 1 IA-29 et. seq of the County Code)
That in compliance with Ordinance No. 142-91 of the Code of Miami -Dade Counr\, Florida, an
employer with fifty (50) or more employees working in Dade County for each .\orkine day durin,
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 (I) 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 case 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 aeency 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-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,
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
property taxes, utility taxes and occupational licenses — which are collected in the norrnal 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 Countyor any of its agencies or instrumentalities.
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 5500,000 or more shall
cont.i ibute to Project Fresh Start, the County's Welfare to Work Initiative. however, if five percent
(5 4) of the liar's work force consists of individuals who reside in Miami -Dade Counry 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. Tne fore2oinri requirement does not pepsin to=overnment entities, net tOr pro;i;
organizations or recipients of ssrant awards.
DOi\IESTC VIOLENCE LEAVE (Resolution 1S5-00. 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 workine 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 "N/A" all affidavits
that do not pertain to this contract.
By:
(Signature of Aunt).. (Date)
SUBSCRIBED AND SWORN TO (or armed) before me this day of
200_ by He/Sheds 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