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STATE OF FLORIDA INDIAN RIVER COUNTY THIS OCERTIFYTHAT ISATRIJEANDC017Fi6CT C THE ORI t !1 OFFICE, L. BY D.C. ATTACHMENT M DATE FOREIGN COUNTRY OF CONCERN AFFIDAVIT — PERSONAL IDENTIFYING INFORMATION CONTRACT Section 287.138, Florida Statutes, prohibits a Florida "Governmental entity" 2 from entering into or extending contracts with any other entity whereby such a contract, or extension thereof, could grant the other entity access to an individual's personal identifying information if that entity is associated with a "Foreign Country of Concern."' Specifically, section 287.138(2), Florida Statutes, prohibits such contracts with any entity that is owned by the government of a Foreign Country of Concern, any entity in which the government of a Foreign Country of Concern has a "controlling interest, 114 and any entity organized under the laws of or which has its principal place of business in a Foreign Country of Concern. As the person authorized to sign on behalf of Respondent, I hereby attest that the company identified above in the section entitled "Respondent Vendor Name" is not an entity owned by the government of a Foreign Country of Concern, no government of a Foreign Country of Concern has a controlling interest in the entity, and the entity has not been organized under the laws of or has its principal place of business in a Foreign Country of Concern. I understand that pursuant to section 287.138, Florida Statutes, I am submitting this affidavit under penalty of perjury. Respondent Vendor Name: Vendor FEIN: Vendor's Authorized Representative Name and Title: Address: City: State: Phone Number: Email Address: Certified By: AUTHORIZED SIGNATURE Print Name and Title: Date: 2 As defined in Section 287.138 (1)(d), Florida Statutes. 3 As defined in Section 287.138 (1)(c), Florida Statutes. 4 As defined in Section 287.138 (1)(a), Florida Statutes. 73 Zip: