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STATE OF FLORIDA <br />INDIAN RIVER COUNTY <br />THIS IS ERTIFYTHATTFMS ATR OCORRECT <br />C� EOR ON i MI TH FFICE <br />RY <br />BY D.C. <br />ATTACHMENT L DATE a ' d <br />FOREIGN COUNTRY OF CONCERN AFFIDAVIT — <br />PERSONAL IDENTIFYING INFORMATION CONTRACT <br />Section 287.138, Florida Statutes, prohibits a Florida "Governmental entity12 from entering <br />into or extending contracts with any other entity whereby such a contract, or extension thereof, <br />could grant the other entity access to an individual's personal identifying information if that <br />entity is associated with a "Foreign Country of Concern."' Specifically, section 287.138(2), <br />Florida Statutes, prohibits such contracts with any entity that is owned by the government of <br />a Foreign Country of Concern, any entity in which the government of a Foreign Country of <br />Concern has a "controlling interest, 114 and any entity organized under the laws of or which has <br />its principal place of business in a Foreign Country of Concern. <br />As the person authorized to sign on behalf of Sub -Recipient, I hereby attest that the <br />company identified above in the section entitled "Sub -Recipient Vendor Name" is not an <br />entity owned by the government of a Foreign Country of Concern, no government of a Foreign <br />Country of Concern has a controlling interest in the entity, and the entity has not been <br />organized under the laws of or has its principal place of business in a Foreign Country of <br />Concern. <br />I understand that pursuant to section 287.138, Florida Statutes, I am submitting this affidavit <br />under penalty of oeriu <br />Sub -Recipient Vendor Name: <br />Vendor FEIN: <br />Vendor's Authorized Representative Name and Title: <br />Address: <br />City: State: Zip: <br />Phone Number: <br />Email Address: <br />Certified By: <br />AUTHORIZED SIGNATURE <br />Print Name and Title: <br />Date: <br />2 As defined in Section 287.138 (1)(d), Florida Statutes. <br />3 As defined in Section 287.138 (1)(c), Florida Statutes. <br />4 As defined in Section 287.138 (1)(a), Florida Statutes. <br />74 <br />