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RFP 2019036 2017-18 CDBG Administration Services <br />CERTIFICATION REGARDING PROHIBITION AGAINST CONTRACTING WITH <br />SCRUTINIZED COMPANIES <br />(This form MUST be submitted with your response) <br />I hereby certify that neither the undersigned entity, nor any of its wholly owned subsidiaries, majority-owned <br />subsidiaries, parent companies, or affiliates of such entities or business associations, that exists for the purpose <br />of making profit have been placed on the Scrutinized Companies that Boycott Israel List created pursuant to s. <br />215.4725 of the Florida Statutes, or are engaged in a boycott of Israel. <br />In addition, if this solicitation is for a contract for goods or services of one million dollars or more, I hereby <br />certify that neither the undersigned entity, nor any of its wholly owned subsidiaries, majority-owned <br />subsidiaries, parent companies, or affiliates of such entities or business associations, that exists for the purpose <br />of making profit are on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies <br />with Activities in the Iran Petroleum Energy Sector List, created pursuant to s. 215.473 of the Florida Statutes, or <br />are engaged in business operations in Cuba or Syria as defined in said statute. <br />I understand and agree that the County may immediately terminate any contract resulting from this solicitation <br />upon written notice if the undersigned entity (or any of those related entities of respondent as defined above by <br />Florida law) are found to have submitted a false certification or any of the following occur with respect to the <br />company or a related entity: (i) it has been placed on the Scrutinized Companies that Boycott Israel List, or is <br />engaged in a boycott of Israel, or (ii) for any contract for goods or services of one million dollars or more, it has <br />been placed on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with <br />Activities in the Iran Petroleum Energy Sector List, or it is found to have been engaged in business operations in <br />Cuba or Syria. <br />Name of Respondent: <br />By: <br />(Authorized Signature) <br />Title: <br />Date: <br />Page 19 of 20 <br />